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4S3O <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Pton ( /�(n e rcG-,'l- 1 e 6c) ` of (/�"r'�I�rylr Cd or) ❑Zoning Status;CUP; <br /> OWNERA R6SSSAlu r,Street City,State,zl�)k 40 re die,�! , '3c___7,2 Deed Restriction; CSM <br /> �,J /- 2 U1 n/� l W l Variance(# ) <br /> HO //PH�ONE U CELL HONE E-MAIL ADDRESS <br /> 1p(�� ( 3 �s37 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME.— rn CONTRACTOR NAME _ <br /> 3.6 //I c Sc hAf 6-r 0 L70 1-n c ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR�� E�ADDRESS a� ) of well/septic <br /> /0a(6 Us ni ly (AAA writer (Ai <br /> (City,State,Zip) , I c3 O (City,State,zip) 3 r O ❑Set <br /> Paf?0�1�n/'L /w,/ PHONE ,1 n e El Si Pan pr-oval from <br /> 7 ?- 3 101 0c) ti 7 0� gb app wn hip. <br /> E-MADRES E-MAIL ADDRESS <br /> /c -otoi e m h k - net ❑Floor lans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) El Elevation of property <br /> ❑ <br /> PARENT /PAR EL NUMBER: Q CURRENT ZONING: ACREAGE: <br /> NUMBER V "CO I le �I "o1 C- 2 c.0 frontage drawn to scale. <br /> TOWNS: SECTION: <br /> a 2-0Mar<<( /S" '/4: cd 1/41/4: S(_ El Driveway permits <br /> ADDRESS: (state,county,town) <br /> 10 .-(G US q cid y I L 7 414-7-jry►anre Cii S3S�6D E Sanitary permits <br /> CSM: LOT SUBDIVISION 'BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION -STAFF REVLEW <br /> PROJECT DESCRIPTION: e ® Zoning District <br /> . EIThis project is a new building or structure. <br /> ❑ Permitted Uses <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: =_❑ RuralAddresS <br /> IFTEVVER REPTIC (62W/OkiOng) <br /> HEIGHT IN FEET: ✓ NUMBER OF STORIES: (Not including basement) <br /> ❑ Wet)and/Floodplain/ <br /> I Shore(and'(atta-chment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished ar ached garages and above grade decks or porches) - <br /> ❑ Erosion Control e`rmit <br /> BASEMENT: 1ST FL(abR: px <br /> 2 (4_ j TOTAL SQUARE FOOTAGE ,, (slopes,disturbances <br /> 2ND FLOOR: 3RD FLOO�2: / fllling�accesS) <br /> "❑ Review Location Survey., <br /> ESTIMATED CONSTRUCTION COST: and-availa6le o dons <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ I ©� .�� p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EINo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EiYes to <br /> 4. Has there been a zoning_permit issued for this property in the past 5 years? IYes ❑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) :Yes 02 o I:Don't know <br /> 7. Is this to correct a violation? ❑Yes 'lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ -► <br /> 545-112(4/08) _ <br />