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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> � C.ne:\— Pe_ 1 \ 'rv\ cA_r\ r-, <br /> ❑Zoning Status; CUP; <br /> OWN SS (Numbe reef,City,S te,Zip) <br /> �� cvo (G /r' Deed Restriction; CSM <br /> HOME PHON CELL Plj N!� -,&f/'DR.E$S variance(# )•aa5`b3 V 77 , ,, m ❑..}1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> n Site Plan including location <br /> AGENT ADDRESS 1 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.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ®PARCEL 6trJo(o10-253-6,15_1 R 3 . 2 g7 frontage drawn to scale. <br /> NUMBER <br /> TOWN IP: SECTION: <br /> D W rk 0c- QV,1NA 1/4; 1/414, n Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3 315 era, id, h iae. <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: «y r <br /> /� J ❑ Zoning District <br /> . ®This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: S" "v PERMIT NUMBER: ❑ Rural Address <br /> EWER (new/existing) <br /> HEIGHT IN FEET:g NUMBER STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> ,, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> /(7117 ❑ Review Location Survey <br /> ESTIMATED ED CONSTRUCTION)COST: -► ♦ -► 5 l o.. and available options. <br /> (Please round to nearest dollar) l <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Flo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eyes , lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 1Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves ❑No <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? rfres ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► -+ --). <br />