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SUPPLEMENT to Web-App # <br /> ZONIN PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA as► "' �"� / <br /> WvACC?. v' S �N Zoning Status; CUP; <br /> OWNER ADD' '•5 (Number,Street,City. State,Zip) D seed Restriction; CSM <br /> '7 ,M�cw L �.�pos W�, s-�:_s Variance(# ) <br /> HOME'HON CELL PHONE E-MAIL ADDRESS <br /> b�^Ty3' � IMO O��'�'`�-� �"" •�e'er ��� Site Plan drawn to scale /� <br /> AGENT 'INFORMATION CONTRACTOR INFORMATION and includes dimensions /'��`-� <br /> AGENT NAM: ` CONTRACTOR NAME A 1 <br /> ' - \- \k.`nr..,,.) LSv►\ck [.cjf 'Site Plan including location 4 <br /> AGENT ADD' CONT ACTOITADDRES p of well/septic <br /> 1 P <br /> Io1OVo.6\∎&V YO koya3.000 <br /> (City.State,Zi. (CI,State,Zip) Setbacks COD/ 4 <br /> .. <br /> PHONE PHONE �,� ... 0‘,-- <br /> � Site Plan approval from <br /> COO /_► '51>' (.p09,--"'4c- "►p0 applicable township. A ._ <br /> E-MAILADDR E-MAIL ADDRESS <br /> 0.1,4 tio ��0...clay .0 One. Z Floor plans to scale <br /> /14.1 <br /> h <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> NPARCE D A — 0r 7 � G: ACREAGE: rifElevation of property / <br /> ❑NUMBS" 4I ,Cao frontage drawn to scale. <br /> TOWNSHIP:, S TI : c y,,/ <br /> /M •GI\ f1 O' 1/a: J ,` W/4: s ,E4 Driveway permit <br /> (state, county, own) <br /> ADDRESS - L N L <br /> teSanitary s- -=:ts <br /> CSM: 5 �\ LOT SUBDIVISION BLOCK/LOT (publi _- ) • <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DE. "IPTION: / r 2. Z �to V f Z sG 4 CG rr Zoning District I <br /> . This • -ct is a new building or structure. e 6 / <br /> p g Q � �Permitted Use?��',Qi�( i <br /> This p • 'ct is an addition/alteration to an existing building�r structure. <br /> SANITARY SE' CE: PERMIT NUMBER: /P i Rural ' •.- s <br /> LEWER AEPTIC new/ <br /> HEIGHT IN F2 .... �(( NUMB R OF STORIES: (Not including basement) / <br /> AREA TO NEAREST SQUARE FOOT: Or -n• fitaChment) <br /> (Outside di e sions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT '1ST FLOOR:'' "� C/ Elopes, ontrol permit <br /> tip j TOTAL SQUARE FOOTAGE: 4 • (slopes,disturbance, f / <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> �7 <br /> /15D—. XReview Location Survey <br /> ESTIMATES I ONSTRUCTIONCOST: -I. -o. $Do O� and available options. ri- <br /> Please ro n. to nearest dollar) <br /> 1. The pro.'e y is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ' l o SDon't know <br /> 2. Is there : etland or floodplain on or near the property? YesIlo QDon't know <br /> 3. Have yo I:Iked with the township about your project and are they in agreement? Yes ENo <br /> 4. Has the e seen a zoning permit issued for this property in the past 5 years? Efres ONo <br /> 5. Is this p •j:ct associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a loc_ is survey required? (see reverse) Yes 8No ['Don't know <br /> 7. Is this to correct a violation? ElYes ' Vo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -► <br /> 545-112(4/08) <br />