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(0 k . <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNERS �� <br /> lR K(}y`— I I Zoning Stajist';CUP; <br /> OWNER AuDRESS (Number,Street,City,S at Zip) <br /> Deed es1riction; CSM <br /> Z4n �y�� ( ZV (fir f Variance'(# ) <br /> HOME PHONE ;s'.1- CELL PHONE E-MAIL ADDRESS ��^ <br /> I�{�l,,Fmp'�r''- �� '�`�� n Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME C. ■ -•CTOR NAME <br /> ( ( ( n Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/seI trc' <br /> (City.State,Zip) (City.State,Zip) n Seto„S <br /> PHONE PHONE r <br /> n Site Plan rQ� om <br /> applicable'o hip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plar to'scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi-us/) n Elevation of p petty <br /> PARENT PARCEL k V--: • U�R�RENTZONING: ACREAGE: <br /> ❑NUMBER (9 I_0 —�i I _s 1364 -Ci VA - 6- frontage c wn to scale. <br /> TOWNSHIP: V SECTION: <br /> ,‘n /: /'/: n Drivew g� <br /> (state, <br /> Vn) <br /> ADDRESS: <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (pubti' il ate n Sanitary S <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5CMQ-1A. ❑ Zonin istrict <br /> . nThis project is a new building or structure. ❑ Per • ed Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> EWER [)EPTIC (new/e ' <br /> HEIGHT IN FEET: N -1 i NUMBER OF STORIES: (Not including basement) <br /> ��.I ❑ Wetla F er aln/ <br /> G� AREA TO NEAREST SQUARE FOOT: Shore ch ment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ Erosion krol permit <br /> BASEMENT: 1ST FLOOR: j <br /> ��^J <br /> 4, TOTAL SQUARE FOOTAGE: 4, (Slop��is�u,rbance, <br /> 2ND FLOOR: 3RD FLOOR: fllingaCC @SS) <br /> r <br /> ❑ Revr',�\ ,'.Location Survey <br /> ESTIMATED CONSTRUCTION COST: �7 o ,�,\ andsaa1�able options. <br /> (Please round to nearest dollar) --0. --s --► --0. $ L 1 I coo•V(� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes No nDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeslo nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ c�'es nNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? nYes [ lo <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) nYes to ❑Don't know <br /> 7. Is this to correct a violation? [Yes nNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -* <br /> 545-112(4408) <br />