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SUPPLEMENT to Web-App # <br /> ZONING ERMIT APPLICATION .countyofdane.com <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OWNER NAM <br /> • I�'IQS �O�.' Scv ping Status; CUP; <br /> OWNER AD RE• (Number,Street,City,State,Zip) <br /> `r.0 CO��� LA! _ V E v\ W t) 'S1 teed Restriction; CSM ) <br /> 1 ariance # <br /> HOME PHONE CELL PHONE E-MAIL As DRESS 'l '•.�,' <br /> .% 0- `0 1 ( ‘ ')- O78 ( i'.' SO iN5a ) a S1W4( r>vtIS. ' �� Si 'Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA'TOR NAME <br /> ife Plan including location <br /> AGENT ADDRES. CONTRA'TOR ADDRESS 1 well/septic <br /> (City,State,Zip) (City,Stat:,Zip) etbacks <br /> PHONE t PHONE ❑ Site Plan ap from <br /> p icablelbwnship. <br /> E-MAIL ADDRESS E-MAIL A•DRESS <br /> IdfiF oor plans to scale <br /> PROPERTY/LOCATION INFORM•T •N http://accessdane.co.dane.wi.us/) levatlon of property <br /> ezIrEPA __.� ZONI : ACREAGE: <br /> ^'� a \c/).3% frontage drawn to scale. <br /> ITL UMBER e ( � v\\_',' 0 T► <br /> TOWNSHIP: }t �t SEC;i i N <br /> (aJJ`4 ,/4: N E ,/4,/4: ,S yJ ❑ Drivewa rmits <br /> ADDRESS: (state unty,,town) <br /> X03 C ( -t Ln1 <br /> CSM: LOT SUBDIVI-ION BLOCK/LOT ❑ Sanita�l,ISermits <br /> 3 5 ' •ubly�,private) <br /> PROPOSED PROJECT INFORMATION ' e°- 1 <br /> PROJECT ESC' • •N: -the. f a :,1;s n-,,, <br /> _y{ A ` ate' WJAJ- " "che <br /> tact <br /> E S <br /> . ❑This prof- is a new building or structure. P`, Ie lae? <br /> ®This proj- is an addition/alteration to an existing! building or structure. 're, ,,~' ', 0 ;y <br /> SANITARYSER PERMIT UMBER: < IAddress <br /> vi 10 <br /> o WER �[SEPTIC ,,,- / <br /> HEIGHT IN FEE ~� `, NUMBER•F TORIES: (Not i cluding basement) °' 'H <br /> AREA TO NE REST SQUA-E FOOT: 4� <br /> (Outside dime ins including unfinished area, attached ga ages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: L ry ��� . ; � 3�TYt <br /> L,�1,� I <br /> 4, TOTAL SQUARE FOOTAGE: '' e er -'� •{ ' ' s <br /> 2ND FLOOR: 3RD FLOOR: `q,f <br /> v <br /> ESTIMATED •NSTRUCTION COST: $guts)IN . a � Ea►rs a <br /> (Please roun. t. nearest dollar) ♦ ♦ ♦ ♦ ♦ �P % = ' 4 <br /> 1. The prope is within 300 feet of a stream or 1001 feet from a pond or lake? ❑Yes Elo(o ❑Don't know <br /> 2. Is there a land or floodplain on or near the pro•erty? ❑Yes No ❑Don't know <br /> 3. Have you .I ed with the township about your proj°ct and are they in agreement'? es ❑No <br /> 4. Has.there • -n a zoning permit issued for this pro•erty in the past 5 years? Yes ❑N�' <br /> 5. Is ths proj-c associated with a rezone/CUP/varia ce(petition/appeal# ) (leave blan f none) <br /> 6. Is a Iocati•n -urvey required? (see reverse) ['Yes o ❑Don't know <br /> 7. Is this to cpr ect a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br /> i <br /> I <br />