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SUPPLEMENT to Web-App # <br /> ZONING " ERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN R NAME <br /> iNE1 L e v Ogo u/zoning Status; CUP; <br /> O RADDRE• (Number,Street,City,State,Zip) <br /> `' Deed Restriction; CSM <br /> 9 p I 0 i' 9 ►'�`-n :.t 120. Y1 1 )1 U(S/� .�3s7 Z j Va ance(# ) <br /> HOME PHONE CELL PHONE / E-MAIL ADDR SS <br /> - Ail' 6 S- - /W 6 C• c • - , . .. . c,D„y Li S'e Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION , and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ' <br /> QtA44, J-i—(c`,oT.Jr,�C t'Qu it ),y ,,,,r3-1, (e,.&c';, _f.(.._ ❑t.te Plan including location <br /> AGENT ADDRE' CONTRACTOR ADDRESS f well/septic <br /> Pa- x ) Z <br /> (City,State,Zip) (City,State,Zip) ,S IR Setbacks <br /> I►i .�� ,�3 X77 <br /> PHONE PHONE ❑ S)t� Plan approval from <br /> 7, 3 7.7 y applicable township. <br /> E-MAIL ADDRES• E-MAIL ADDRESS ✓'Floor laps t Cale <br /> 4.1 c‘ Irt. P t : i . 'A P <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevati Of pro rty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL r/y ,Q / /� / 0. -^7 5-r— frontage dra to scale. <br /> NUMBER D�0 d 7�OS?'yJ /®• '/`/ /7 lr Z <br /> TOWNSHIP: SECTION: <br /> s/61(2-/P(2-/ ,o, k •E '.i 1/4: J kA., 1/4'/4: " F ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 70 e l ii-tY /9 u N ev.,.,J ) ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> / ? / , 3 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESC•I'TION: 1 f <br /> r 0 'X I y /s1 G e o Ll■A-,6 /° mil, a `Zoning District <br /> ❑This prof-• is a new building or structure. ermitted Use? <br /> lil This proj-c is an addition/alteration to an existing building or structure. <br /> SANITARY SER C:: PERMIT NUMBER: Rural Address <br /> S:WER SEPTIC i3— ? 0,9- , 0 7-3 y (new/existing) <br /> HEIGHT IN FEE NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoretand (attachment) <br /> (Outside dim- sons including unfinished area, attached garages and above grade decks or porches) Li <br /> BASEMENT: 1ST FLOOR: U ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: � _-1v) <br /> filling/access) <br /> -- ❑ Review Location Survey/ <br /> ESTIMATED [ •NSTRUCTION COST: z ' and available options. �� <br /> (Please rouni ts nearest dollar) ♦ ♦ ♦ ♦ ♦ / <br /> 1. The prope is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 2 No ❑Don't know <br /> 2. Is there a Nivz.tland or floodplain on or near the property? ❑Yes M No n Don't know <br /> 3. Have you tal ed with the township about your project and are they in agreement? 0Yes n No <br /> 4. Has there b=en a zoning permit issued for this property in the past 5 years? El Yes ❑No <br /> 5. Is this proj' c associated with a rezone/CUP/variance (petition/appeal# ) (leave blank if none) <br /> 6. Is a locati n .urvey required? (see reverse) ❑Yes QNo n Don't know <br /> 7. Is this to c recta violation? ❑Yes No <br /> ,y� . ,. <br /> �- i I c,„ APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ♦ -♦ <br /> 545112(4/08) <br />