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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 /> -S;177" end 7[ 1- c If l h <br /> c "'0 ❑ Zoning Status; CUP; <br /> OWNERADD5XS (Number,Street,City,State,Zip) <br /> /03 .• q7 r �l- �� �� 4l S3s ? Variance Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL DR SS <br /> 3r02 S-. 533 - `,7 yz ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> A T NAME C CTOR NAM / ` <br /> (/ �� �7,✓ /J�; � � pdel d ❑ Site Plan including location <br /> AGENT ADD SS CONTRA ORA RESS of well/septic <br /> ( State,Zip ti (Cit ,State,Zip ❑ Setbacks <br /> P NE / PHON / ❑ Site Plan approval from <br /> �c9 1•45S aZ S4�5� COQ- l0 'r-.2 s:2s- applicable township. <br /> E-' TAIL AD DRESS E-MAIL ADDRESS <br /> ix a s ;#2_, ,,,ez,;, ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL �yy pp�, �f frontage drawn to scale. <br /> NUMBER D4 2-"65 . 63—%TOr�"O / oli 05/ <br /> TOWNSHIP <br /> SECTION: <br /> L"� '/o: '/4'/e: ❑ Driveway permits <br /> ADDRESS: /A (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> /0 8/ . y!/!QJ¢ (public,private) <br /> PROPOSED PROJECT INFORMATION Fr; <br /> PROJECT DES IPTIO �0� � ��' <br /> f'f�e� c� c ir4 �S`C5-/ /e C Z Dis <br /> . 0 This project is a new building or structure. It Oct Use.. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: � i •° eSS <br /> SEWER SEPTIC /3-P?O/S- ©Oat o 2_ l' (hiiflexisting) <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) s ' <br /> AREA TO NEAREST SQUARE FOOT: <br /> ay, <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ,�� LI'� <br /> t o s a a <br /> BASEMENT: 1ST FLOOR: <br /> /QS'/ 07/ 7C? ,# G ,+ <br /> �. � <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3/ 7/. /' ';° <br /> t3 Review e <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ �S e et,''' <br /> (Please round to nearest dollar) ( �� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes g No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EI 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 ®No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IR No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br />