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SUPPLEMENT to Web-App # <br /> ZONING ' ERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME S-I er / c24 <br /> l), Zoning Status; CUP; <br /> OWNER RE umberl reet,city, tat e, �I ( ic./-0 n ��5 ��� Variance #4 r �ty Zi �j J Deed Restriction; CSM <br /> HOME PHONE CELL PHONE _ -MAIL ADDRESS ( ) <br /> ,a$g — 34 . 3 '' Y'D VCcci'1 l'c0 4ho°• ce)m N Site Plan drawn to scale �1 <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions �1 <br /> AGENT NAME CONTRA TOR NAME <br /> Cleary bU( idln 5' Site •.- uding location <br /> AGENT ADDRES. C CTOR A6DRRESS o well/septic <br /> V O SOY 75-O 0 C 3/500/A <br /> (City,State,Zip) (City,State,Zip) ,� Setbacks <br /> Vero nq ,_s-cter-ce3 <br /> PHONE PHONE Site Plan approval from <br /> applicable township. // <br /> E-MAIL ADDRES• E-MAIL ADDRESS <br /> !,/ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT II PARCEL NU :ER: CURRENT ZONIN : ACREAG : 2. Elevation of property <br /> 0 PARCEL 0 7 __G -. 4 l (r frontage drawn to scale. 7. <br /> NUMBER • o!r • 1 �.� v 1 l <br /> TOWNSHIP: / / CTION• <br /> f'�fr ,r 1eT0/7 u, 1/4: /Vii '/4'/4: 5 Driveway perm' <br /> ADDRESS: 1 (state,coun ,,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary p- ■' s <br /> r <br /> r_____________ (public, .M <br /> PROPOSED PROJECT INFORMATION �j F l <br /> PROJECT DESC' •N: /r ,;;17' <br /> i <br /> i � • x 3 a Y /- t°I ' . ''''/',1' Dish <br /> � : <br /> . 2 l nis prof: is a new building or structure. ' <br /> This prof: is an addition/alteration to an existing building or structure. A 40.1r4 <br /> t -SANITARY SERV PERMIT NUMBER: '" <br /> ER OSEPTIC ° ► �# <br /> HEIGH T IN FEET: /4 NUMBEF STORIES: (Not including basement) , +. <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dime •ns including unfinished area,attached garages and above grade decks or porches) y <br /> BASEMENT: 1ST FLOOR: TOTAL SQUARE FOOTAGE: s a r sBE ►dt ? t j/ <br /> 2ND FLOOR: 3RD FLOOR: <br /> ly 610 <br /> ESTIMATED I 0 STRUCTION COST: ♦ ♦ ♦ ♦ ♦ ,a aa.,a <br /> (Please round to nearest dollar) OO. - - <br /> 1. The prope y is within 300 feet of a stream or 1000 feet from a pond or lake? UYes 126o ❑Don't know <br /> 2. Is there a e land or floodplain on or near the property? ['Yes 'TKO El Don't know <br /> 3. Have you t:l ed with the township about your project and are they in agreement? EYes 1[]rNo <br /> 4. Has there 'e-n a zoning permit issued for this property in the past 5 years? El Yes [ KO <br /> 5. Is this prof:ci associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a locatio urvey required? (see reverse) EYes E No 6n't know <br /> 7. Is this to co rr-ct a violation? JYes i2<0 <br /> /SY 0(f a APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />