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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 4 <br /> (iVS�A� c ��`' ` `'� CD �'��`� \.� ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Num r,Street,City,State,Zip) Deed Restriction; CSM <br /> \'3� v a�L YA ��`�-'1 ,,, `Rt i'IP1 05- Scr. Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDI.E - <br /> CcOt-71a•( -11/4.( . CV:- iiA• ,',. vd I # (II. r 'p Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ 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/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ NUMBER c1a locl 1 frontage drawn to scale. <br /> -303- -■ G <br /> TOWNSHIP: < �1 0 SECTION: <br /> Y l � j o�-� ,�4: ,/4,/4: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: \ � <br /> 13 ( ' V el,- Sa` ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: I <br /> This project is a new building or structure. U P . Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: " ,' <br /> SEWER SEPTIC t= "' ° f` <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> M 1 f4Wi <br /> a°a� <br /> AREA TO NEAREST SQUARE FOOT: � ,l, <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) I* si 41 <br /> BASEMENT: 1ST FLOOR. <br /> n 4, TOTAL SQUARE FOOTAGE: 4, <br /> (slopes'disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 3c=69 ,, 001100M440 .6 <br /> d r . ,04,, <br /> ,„‘,t,; ,-,-,;., ' <br /> Review,,..00Bt 3',i114 <br /> ESTIMATED CONSTRUCTION COST: Q0R � B; <br /> (Please round to nearest dollar) ♦ '♦ "♦ ♦ _I, ♦ )000 -- aa <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eyes ❑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) Eyes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Eyes ❑No <br /> APPLICATION MUS BE SIGNED <br /> (Continue on Back)T -* <br /> 545-112(4/08) <br />