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" I SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyordane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> A'Ise/I. <"" 'n 5'e` ( ❑ Zoning Status; CUP; <br /> OWNERADDRE (Number,Street,City,State,Zip) /, Deed Restriction; CSM <br /> 55 3) w: `n c-tC1�,^+-,o C 4rc' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (vcs . )31/45--5-1)4 601.--335-1-1 b(7,71 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> ❑ <br /> PARENT PARCELNUM:ER: A y`Da �J.IRRENTZONING: ACREAGE: <br /> PARCEL 17`I,( (�3�y .t!" "`� �y p frontage drawn to scale. <br /> NUMBER F ' - • --• -- - - . -� DV /9i 4/37 <br /> TOWNSHIP: SECTION: <br /> •D>"e 0 1/4: 1/41/4; ❑ Driveway permits <br /> �'/ ✓l (state,county,town) <br /> ADDRESS: <br /> 65,3/ 1'3 ne�1y.rcr,0e-t ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> I b; <br /> PROPOSED PROJECT INFORMATION STAFF RE+ItiArc <br /> PROJECT DESCRIPTION: n 1_1 <br /> 3)e-�'r*c .Ao4 ✓-1 e e 701 GL)►� <br /> . RThis project is a new building or structure. a Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> ❑ Rulal dress ' <br /> SANITARY SERVICE: PERMIT NUMBER: . ;, <br /> f SEWER SEPTIC (new/e st• g) 3i-, <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 7 ' / Ir a o/ tland�odplainl <br /> AREA TO NEAREST SQUARE FOOT: hdrtrriettt . <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> Erosio of • <br /> BASEMENT: 1ST FLOOR: y <br /> /�Dp + TOTAL SQUARE FOOTAGE: + (slopes;diistu/ �:,.• <br /> 2ND FLOOR: 3RD FLOOR: tt fillrlglacess}__ <br /> 12,19° S c f © Re $.. r t�eY <br /> ESTIMATED CONSTRUCTION COST: and fir. ' pti '', <br /> (Please round to nearest dollar) ♦ ♦ ♦ '♦ ♦ ♦ $ /4, ?,69. ;< <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? aY es 'ON° ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? •Yes lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 21 es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 0 Yes--;3No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ■ o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes r o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />