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� ---- 724) 3-.7. 0 SUPPLEMENT to Web-App N <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �/� 1 //��- <br /> ai-rd n8 tine«� f• (e- ()O erct4r(/2 UC'i'kktr (-UV� ❑Zoning Status;CUP; <br /> OWNER AggR,�SSA� r,�eet,City,StateM)4 f i4 r / ,�� c 3c� Deed Restriction;CSM <br /> l✓U 3 (! ��'YYY c W( a. Variance(# ) <br /> HO //P�H'ONE CELL y HONE E-MAIL ADDRESS <br /> (0O� 137 c'531 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME.- CONTRACTOR NAME <br /> J 06 plc.-1)( Sc r1iti 17tt 6- O vi 1_n c ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> `00f6 Us gtj Ily Wkik wu r <br /> (City,State,Zip))y� c` O (City,State,Zip) r a ❑Set <br /> PQ�i(�O /ll( J PHONE CJ d ❑SI ' Pc�►�: .valfrom <br /> �pd�) 7�?- 3 cOl QOO ii 7 0�O app' n.hip. <br /> EMAIL DDRES E-MAIL ADDRESS <br /> c -oA n e /II h tc - net Floor ,lans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBEER: CURRENT ZONING' ACREAGE <br /> ❑NUMBER 0 g©(O I U�1 q1 "Q O1 C- or` S.o frontage drawn to scale. <br /> TOWNSHIP SECTION <br /> i 1a 7-61116-AiE IS" v.: 3 W ih : “-= ❑Driveway permits <br /> ADDRESS. y� 0); (state,county,town) <br /> / O �( & US body Ili Ifl ,7 ante 536 d ❑Sanitary permits �,/ <br /> r <br /> CSM: LOT SUBDIVISION BLOCK/LOT Y l 7 <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAPP REVIEW <br /> PROJECT DESCRIPTION: . ` <br /> IC � <br /> /1 11 t- CI Zoning District <br /> . <br /> This project is a neng or structure. ❑ Permitted Use? <br /> MThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER ❑ Rural Address <br /> EWER 'EPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES (Not including basement) <br /> ' 2.(7.f Q ❑ Wetiand/Floodplain/ <br /> I Shoreland (attachment) <br /> REATO NE#REST SQUARE FOOT: �G y <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 15—o �I <br /> ❑ ErosionControl permit S vJ NA <br /> BASEMENT: 1ST FLO r/ u <br /> 2 <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> `G filling/access) Si'Vl 2... cS <br /> 2ND FLOOR 3RD FLOOR e 62.-,L <br /> j✓r� ❑ ��t5 Review Location Survey v <br /> ESTIMATED CONSTRUCTION COST: $ /{� ,�/� 1 and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ $ 1/ s-60/ Ow o0 p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [lies IANo ❑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? 1 es to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? e 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) ['Yes 17jVo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes INNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —+ --• <br />