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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TVP PROVE <br /> OWNER NAME I r 9. / <br /> 11'y za✓``,-�- ❑ Zoning Sta �, CUP;L. <br /> OWNER ADDR SS (Number,Street,City,State,Zi ) Deed Strictlon; CSM <br /> r / i-a-/ - �L�� `� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR' S <br /> 0 38— 3. x 6. 6e 8 - 3 :2.-: N 4 n Site Plan dra n t cale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and include ' ensions <br /> AGENT NAME CONTRACTOR NAME <br /> n Site PI rrtl ing location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of we /s i <br /> (City,State,Zip) (City,State,Zip) <br /> I I Setba(SICs <br /> PHONE PHONE ❑ Site Pla pro I from <br /> applica <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n Floor pla ' scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: n Elevation f pro rty <br /> 1 n PARCEL frontage d a to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/4: 1/41A: ❑ Drivew y p�sr1vts <br /> ADDRESS: (Stat� , to ) <br /> CSM: LOT SUBDIVISION BLOCK/LOT n Sanitary permits <br /> (. . , private) <br /> PROPOSED PROJECT INFORMATION STAFF R IEW <br /> PROJECT DESCRIPTION: pp � <br /> ,e�'� �0 k l Z4--t e LI Zoni 'strict <br /> . --This project is a new building or structure. �`ll ❑ Per tt se? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: C1 Rural Address <br /> I!/KLSEWER nSEPTIC (new/e( s tn ) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> LI Wetla /FI it plain/ <br /> Shor a . 'r hment) <br /> L/ AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ Erosio CQn`X l permit <br /> 4 TOTAL SQUARE FOOTAGE: j, (slop d s f. 0:nce, <br /> 2ND FLOOR: 3RD FLOOR: fillln access) <br /> ❑ Rev' .: ion Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► ♦ -5.. $ and l.1 I tioptions. <br /> (Please round to nearest dollar) <br /> A <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? E Yes AI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 1■ o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 37 Yes •No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 41 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) n Yes It No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Jo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —* - <br /> 545-112(4/08) <br />