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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,- r t 0., d //Q r Z 0. b e ❑ Zoning Status; CUP; <br /> OW ADDRESS (Number,Street,City,Stat Zip) <br /> 1'6 0 C.-1-t_G.-I-c 5 ti 5 lc ',,,�- w-7. s3 s 7 Deed Restriction; CSM <br /> 9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> cis-)3 - (, '-/( 3 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGaNT NAME/ CONTRACTOR NAME <br /> ,Jrt 0 r.,.4--- 1( ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> '2 5-7 c k 0,-lei Z"' <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> 5TvJSKA- ,'.-1. S? Tb' <br /> PHONE PHONE ❑ Site Plan approval from <br /> S 13 - 1 1 5- 5 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 /> PARENT PARCEL NUMBER: CU RRENTZONING: ACREAGE: <br /> ❑ PARCEL 0(010 '1°16605 �L_ frontage drawn to scale. <br /> NUMBER _ \ <br /> TOWNSHIP: SECTION: <br /> '/4: %.14.. ❑ Driveway permits <br /> (g 9 wpiit_ccr\' (state,county,town) <br /> ADDRESS: 0 en C� ,, >�`J <br /> CSM: LOT SUBDIVISION BLOCK/LOT El (public, permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION T <br /> PROJECT DESCRIPTION: C , <br /> S'>< S 'D<<k 3 ` .c v p Zoning <br /> . ❑This project is a new building or structure. U P ,, Use? <br /> ❑This project is an addition/alteration to an existing building or structure. / <br /> SANITARY SERVICE: PERMIT NUMBER: ratA dre <br /> nsEWER nsEPTIC €' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Cl Wetn <br /> r <br /> AREA TO NEAREST SQUARE FOOT: ,• "?„ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) . : • <br /> 1 <br /> BASEMENT: 1ST FLOOR: l <br /> vi 4, TOTAL SQUARE FOOTAGE: + • "disturb,„ <br /> 2ND FLOOR: 3RD FLOOR: <br /> I& <br /> ESTIMATED CONSTRUCTION COST: / *�a €s ;' <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ' ''_ �_ 6,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ,Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Flo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? E.Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Eallo <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? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -o <br /> 545-112(4)08) <br />