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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM(S- <br /> V Lki L a, V v I'M wueN e r .n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 'j�� I Deed Restriction; CSM <br /> 15�5 "BwrVe_ KA• Leer AIWL s35 ( Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR S <br /> Wt. . #' i 4 W I PkWt e e✓ 1•GA Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> •GENT NAME CONTRACTOR N M SC <br /> St- <br /> l V\145 ' . n Site Plan including location <br /> AGENT AD•ESS CONTRACTOR ADD_ _-SS, of well/septic <br /> AD <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE �/1 �S_22.5_�-Z0 ❑ Site Plan approval from <br /> SCo i�ltkprwx applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> 5 tzts k_ 5t v-.5 -' -}, ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 111 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ElPARCEL <br /> NUMBER a8/0711 'Oki• 8 310 •0 Al . L---x 4. 1 S9 frontage drawn to scale. <br /> TOWNS P: SECTION: <br /> 2C-fay_ 1/4: 1/1/o: ❑ Driveway permits <br /> ADDRESS: ,,/' I , (state, county,town) <br /> 5� W i D V4 '• WI 353 t I] Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> , le J Zoning District <br /> ©This project is a new building or structure. J Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: ServCS MlouSe PERMIT NUMBER: ❑ Rural Address <br /> nSEWER SEPTIC MI (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 1 ] Wetland/Floodp(ain/ <br /> `7' S 1 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: r�`n D filling/access) <br /> I!T I R V2"0 t) J Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ •p 10,000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes INo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? III Yes a, o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ,JVo <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 ENo ❑Don't know <br /> I 7. Is this to correct a violation? ❑Yes ,No <br /> SI\ I14 APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -i <br /> 545-112(4/08) <br />