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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 /> L E `' M.o. tf"'"- ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> /b 5 7 F ! b 0 I,... (,v fr'T Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS , <br /> for - , 35.2 /6/y L At A-t*Cf"-P 0414I(Co ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 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/) <br /> •. Elevation of property <br /> PARENT PAR CURRENT URRENTZONIN ACREAGE: <br /> ❑ PARCEL • '0 n frontage drawn to scale. <br /> NUMBER v <br /> TOWNS R. SECTION: <br /> (/ /a Ih.► '/4: '/4'/4: ❑ Driveway permits <br /> ADDRE S: (state,county,town) <br /> e • leK3 I k_ .R 9 4/7?"-0 w l wt ' ❑ Sanitary permits <br /> CSM: LOT ( 1 DIVISION BLOCK/LOT <br /> qbb� (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJ T DESCRIPTION: <br /> ��. �� -� 't p k« 1 (06.52( 4 � C ing District, � <br /> . ❑This project is a new building or structure. via, ¥ U , <br /> ©This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ©.,Rural Ac dress <br /> SEWER SEPTIC �v/ <br /> i v� <br /> HEIGHT IN FEET:ifiry ' l NUMBER OF STORIES: (Not including basement) �a <br /> AREA TO NEAREST SQUARE FOOT: e,.: ,-, � <br /> (Outside dimensions luding unfinished area, attached garages and above grade decks or porches) ;� <br /> BASEMENT: 1ST FLOOR: r t� yy ��0 # , <br /> GtJ 4, TOTAL SQUARE FOOTAGE. • ysr <br /> 2ND FLOOR: 3RD FLOOR: <br /> Zg8 e <br /> Li Rem . ' v y <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ ♦ -+ ♦ ■ ♦ £.71 <br /> / �eCiE <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ,CI No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? RYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes .O 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) Eyes FNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EITCro <br /> AAU k)T BE SIG NE <br /> (Continue PPLIC on TION BacMS <br /> 545-112(4/08) <br />