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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 /> e �/�/ <br /> � 1 to U '-/ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Si D �} � ed) ro 140t5VNr U j 5'57/8 <br /> Deed Restriction; CSM <br /> i Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> !c>$-2 37-6 ,1.7 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite rX R-p' e "&i2 L-o-ef( i toe jj Po0L S ❑Site Plan including location <br /> AGE■ CONTRACTOR ADDRESS of well/septic <br /> 3131$ co drub( ?cQ A B <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> M O 0166 N, lv c 5-.1,7 1 e <br /> PHONE PHONE ❑Site Plan approval from <br /> (,fig _2.2.2.--/ 7 30 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> c/C/! a.' CI-7.6?ac»lijovoLc„ Gpwl ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 1=1 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 019/0711-ow._87ZO-2 -7, ti-4 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> C-C- q-C� e 2 OV`P '/4: /4/4; ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3)OS 6i‘+`;f 0 i 1 Q ( IAO(SON, w ? 7/e ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /1/ X &' , )5,2v v iv el SLt.+,yki Poo L ❑ Zoning District <br /> . [f-This project is a new building or structure. ❑ Permitted Use?'' <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosIIonControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 7� <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �O,,c o and available options. <br /> -0. -0 -10(Please round to nearest dollar) -0. <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 ❑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? ❑Yes ❑No Om knx'' <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) Lives gNo ['Don't know <br /> 7. Is this to correct a violation? ['Yes IljNo <br /> /1— 1-'6 Li) ` ec__ APPLICATION MUST BE SIGNED <br /> 545-»2 taros) �� A\ Back) --0 -+S � . <br />