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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNEnEiv . pp <br /> `1— rl6, -g0VJ } Zoning Status;CUP- <br /> OWNER ADDRE 3S&llumber,Street,City,State,Zip) S3 5"I rl Deed Restriction; <br /> d CI co go A) "R d ( 5 Luz, 1-to r Variance(# ) <br /> HOME PHONE CELL PHONE cjl E-MAIL ADDRESS <br /> �"'5 r1 !`7�1 B . P e 14e-24.-' Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> If-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/) <br /> PARENT PARCEL NUMBER: <br /> —4)5649-CURRENT ZONING: ACREAGE: Elevation of property <br /> El NUMBER (./�to" 2-12- c kit- - • g frontage drawn to scale. <br /> TOWNSHIP: t SECTI I.: <br /> 6 MAI\ Gr -1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: I /� (state,county,town)la l b 6� ( ❑ Sanitary permits <br /> CSM: / LOT SUBDIVISION BLOCK/LOT <br /> (o f J (public,private) <br /> PROPOSED PROJECT INFORMATION 44' -- <br /> PROJE D S RI ION: l�_iv CT <br /> . ❑T is project is a new building or structure. Use? <br /> ir-This project is an addition/alteration to an existing building or structure. yy <br /> SANITARY SERVICE: PERMIT NUMBER: ® Rural it/r -,zei <br /> FISEWER EPTIC (new/existing)r 4 'elf' <br /> HEIGHT IN FEET O� ( NUMBER OF STORIES: (Not including basement) <br /> I 33 Wei dblelef <br /> Orel nd (at hi t) <br /> AREA TO NEAREST SQUARE FOOT: <br /> dimens ons including unfinished area, attached garages and above grade decks or porches) Erosioritrol permit <br /> BASEMENT: 1ST FLOOR: il TOTAL SQUARE FOOTAGE: <br /> o:: <br /> f lling/a ess) <br /> 2ND FLOOR: 3RD FLOOR: tJ^ <br /> / � <br /> a eviiiiilbcation Survey <br /> ESTIMATED .ONSTRUCTION COST: O D 0 • qp r� ! , evadable o}�s <br /> ♦ - ♦ –► ♦ rii <br /> (Please round to nearest dollar) , � r,�,,,,, „ ��� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes I rJ lac ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeso ❑Don't know <br /> 3. Have you .alked with the township about your project and are they in agreement'? ❑Yes Leo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 121-es ❑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) es ❑No ❑Don't know <br /> 7. Is this to cprrect a violation? ❑Yes [ Jo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -0 <br /> 545-112(4/08) <br />