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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN NAME — t �d <br /> IN <br /> I./--L 1 i�E 1 ❑ Zoning Status; CUP; <br /> OWNER DD ESS (Number Street,City,State, ip) Deed Restriction; CSM <br /> ht)D n i L t- Variance(# ) <br /> H•ME PHONE CELL PHONE E-MAIL ADDRESS <br /> — I t I ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGIEr NAME CONTRACTOR NAME <br /> [C 1{- j f 1W,D LA-d'{ -14 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 53? C�IN�OF'1 (LL- �)'3 <br /> (C' State, ip) (City,State,Zip) ❑ Setbacks <br /> �OKLYN (Al J <br /> PHONE . r PHONE El Site Plan approval from <br /> c— '`cS 2 i�C) applicable township. <br /> Eie'D <br /> AIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> El Elevation of property <br /> PARENT PARCEL UMBER: CUR NT ONIN ACREAGE: <br /> ❑ PARCEL ()310/ / `90�/� /5- frontage drawn to scale. <br /> NUMBER (//`' <br /> TOWN P: SECTION: <br /> IcLit t--A4 Q ) 1/4: 1 IA: ❑ Driveway permits <br /> AD//D/lR s: 11 11 -p V v j f (state,county,town) <br /> A ® W/NAM LL ?4J B W t.Ll IVr W f 3�Z1 El Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /( ' ")(1 z' F')(TE'&/6 iu OP EX'S-Flit/6- 3. -",(1.SOK) PoeH- ® ding District" <br /> El This project is a new building or structure. t ?" <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: C'Rural ',° ess <br /> _ Hsi 5 �r/ � , <br /> nSEWER IASEPTIC (iew/ ,,:: g) <br /> 4 dj� <br /> HEIGHT IN FEET: l NUMBER OF STORIES: (Not including basement) LI We lain/ <br /> AREA TO NEAREST SQUARE FOOT: ' ` fit <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) 13 ESicontivl per <br /> BASEMENT: 1ST FLOOR: <br /> 19'Z, 4, TOTAL SQUARE FOOTAGE: 4, ' (Slopes,disturbance, <br /> e, <br /> Mang/amass) <br /> 2ND FLOOR: 3RD FLOOR: / 2_ <br /> Li R "L °6 <br /> evIiiii ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ' avail =,..i a ., <br /> (Please round to nearest dollar) l�ODD 4, <br /> I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ICI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes ENo <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) Dyes in No p Don't know <br /> 7. Is this to correct a violation? EYes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0 ■ -+ <br /> 545-112(4/08) <br />