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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 /> 3 OY1 'i \ l Q-\c��,li:' ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Num r,Street,City,State,Zip) Deed Restriction; CSM <br /> ,3,c,0 6%-k d,=,.. K � ,W t Variance(# ) <br /> HOME PHONE CELL P E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> �j �, "'Ob\1‘kr" ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD of well/septic <br /> 3\\\ t <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Nc.(\d o.c\ft,...-•9,_ W l <br /> PHONE PH NE ❑ Site Plan approval from <br /> �jd� 51 (o CI 1 t' applicable township. <br /> E-MAIL ADDRESS -MAIL ADDRES <br /> b C- \ ,, ,T .ivr cwL 1 , ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> Efrontage drawn to scale. <br /> NUMBER G:1`11'b(.1�b-t7-5061° — # ql <br /> TOWNSHIP: SECTION: <br /> b '/4: '/4'/4; ❑ Driveway permits <br /> V►�!1'C1 (state, county,town) <br /> ADDRESS: <br /> •L $ \0'��^ C'c \ 0`(\ ) ).• % ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ST REVIEW <br /> PROJECT DESCRIPTION: Q _ ) '" <br /> imiNA t- ) (41. dijniin I MISfOCt <br /> ❑This project is a new building or structure. <br /> • <br /> 11 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ress � <br /> SEWER ( / � <br /> HEIGHT IN FE T: NUMBER OF STORIES: (Not including basement) <br /> ji Si3 y <br /> t Slr'iand � <br /> AREA TO NEAREST SQUARE FOOT: ; <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: i,�., $�~Q � <br /> 4, TOTAL SQUARE FOOTAGE: ,�, i � ,s�rbance, <br /> 2ND FLOOR: 3RD FLOOR: `a <br /> tt;;#evieLo�on Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ _+ ♦ -4 ♦ ♦ `• D- <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes E 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 <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 El No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes g No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ <br /> 545-112(4/08) <br />