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. SUPPLEMtirl to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> V e (tl ct ri ov i L_L ❑ Zoning Status' P; <br /> OWNER ADDRESS (Number, set,City, te. r Deed es ' tion;CSM <br /> `J(3 0 I i t � I 0 I L-t )) ) 1 )j) 7,tAzg 57 i3 Varian (#_ __--) <br /> H M O CELL PHONE E-MAIL ADDRESS <br /> -- _�7�� ❑ Site Plap dr wn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and inc es dimensions <br /> AGENT NAME CONTRACTOR NAME location <br /> 5 0 Site PI i ding <br /> � �� �� Ai � V e <br /> AGENT ADDRESS CONTRACTOR ADDRESS of welU ptic <br /> (City.Sate,zip) (City,state,Zip) 0 Setbacks <br /> ❑ Site PI � I from <br /> PHONE PHONE appli b. ship: <br /> E-MAILADDRESS E-MAIL ADDRESS ❑ Floor planVcale <br /> PROPERTY/LOCATION INFORMATION (http:/,'accessdane.co.dane.wi.us/) ❑ Elevatioc ol,gropertY <br /> PARENT - 1- Al T-I • _ •1-1•d` •I• v ACREAGE: ,� frontage to scale. <br /> ❑ PARCEL 0' 0 A L <br /> NUMBER <br /> TOWNSHIP: SECTION: 1 ❑.Drive y rm <br /> C.M ��4. I'4. - � (state ,town) <br /> ADDRESS: \,` w'S y �1 • <br /> 0San <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub . te)/ <br /> PROPOSED PROJECT INFORMATION ' <br /> PROJECT DESCRIPTION: ' 1 <br /> _ _ v.,,,, co rtStro,A.A.-"i0-) 1 - -- - ,- <br /> . 'his project is a new building or structure. • <br /> ❑This project is an addition/alteration to an existing building or structure. — <br /> 6 i <br /> SANITARY SERVICE: — — PEHMQ NUMBER� <br /> SEWER 0 SEPTIC 6t) <br /> HEIGHT IN FEET A , _ NUMBER OF STORIES! (Not including basement) <br /> j� 1 <br /> AREA TO N AREST SQUARE FOOT: porches) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or p ) <br /> BASEMENT: 1 1ST FLOOR Cfi rrT0TAL SQUARE FOOTAGE: j <br /> 2ND FLOOR: 3RD FLOOR: L., 4,.....ri...7_. <br /> •ESTIMATED CONSTRUCTION COST: �4'8 O C� o <br /> -► -► -► -► -0. -► <br /> (Please round to nearest dollar) ,�..,/ _ <br /> 1J No ❑Don't know <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Oyes <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes [iNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement?Has there been a zoning ,� es ❑No <br /> 4. 9 P t permit issued for this property in the past 5 years? Yes 0 No <br /> 5. Is this project associated-with a rezone/CUP/variance(petition/appeal# ) (leyve blank if none) <br /> 6. Is a location survey required? (see re <br /> Yes []No 0 Don't know <br /> 7. Is this to correct a violation? ❑Yes VNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ `♦ '4, <br /> 545-112(4103) <br />