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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> OWN,AME / r()`L CUSTOMER TO PROVIDE <br /> • I t' <br /> EgADDIV,SS (N!ber,Street,City,State,Zip) la mt ❑ Zoning Status;CUP; <br /> `J `�/6 i Deed Restriction; CSM <br /> H PHONE r, CELL PHONE E-MAILADDRESS Variance(# ) <br /> G <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION <br /> CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CON RAC OR NAME <br /> C1OR ❑ Site Plan including location <br /> AGENT ADDRESS CON�iTO DDRESS <br /> 3 �° .;, -�s of well/septic <br /> (City,State,Zip) (City,State, ip) / ❑ Setbacks jpiii_ <br /> PHONE PHtgESO.6 <br /> ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> P ENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ARCEL <br /> NUMBER �- ( I. 21 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> „` /4; /.1/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 39 q Co d0Ty-I Rh <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> Gs�� (public, private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION:` <br /> • is project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. r , <br /> SANITARY SERVICE: <br /> PERMIT NUMBER: <br /> (SEWER f "" Af=;nd� ' <br /> HEIGHT IN F of ' <br /> NUMBER OF STORIES: (Not including basement) t " <br /> ��£la ,.*,'.f•l� s <br /> AREA TO NEAREST SQUARE FOOT: ~ , " tl l <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) j � <br /> BASENjENT 1ST FLOOR: TOaI s ¢e. 3 jf <br /> !!{{66 go S C 1 TOTAL SQUARE FOOTAGE s <br /> 2ND FLOOR: � [e o j� <br /> 3RD FLOOR: 4 <br /> a 3� 7O 36 Al <br /> ESTIMATED CONSTRUCTION COST: By s` <br /> (Please round to nearest dollar) ♦ "♦ ♦ "► ♦ —► �/� G <br /> r <br /> ;ter x. �. • <br /> 5/-1-t5 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 31Qo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes fftWo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Jres ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes [JPfo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# <br /> (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 [iNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 iaiosi (Continue on Back) -♦ <br />