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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME Q / <br /> /t_/l .l'- '34- 5a/'? - /'4. Er-0 tYJ n Zoning Status; CUP; <br /> O NER ADDRESS (Number,Street,City,State,Zi )r f T , , (�,"I sa r- �� Deed Restr'cti CSM <br /> qyg / Sr/044)V /{�<. q'c, /r—e:4 j / C35 J Variance(#v ) <br /> HOME PHONE pp CELL P,I ONE J E-MAIL ADDRESS <br /> 6 08 I/6j''46/I, n Site Plan draw o scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includ Imensions <br /> AGENT NAME CONTRACTOR NAME �T /� ,� i I�I <br /> L/7 i/O/1 cX� ,4 c ..cc J I I Site PI n i /4...g location <br /> AGENT ADDRESS CONTRACTOR/ADDRESS of well/ at <br /> X32 r Doses R <br /> (City,State,Zip) (City,State,Zip) ❑ Set�ajks <br /> /`1ad'5G") wI57/8 v <br /> PHONE PHONE SfeI✓G n Site la oval from <br /> 608_3 .' '— 6 W Sf f.frr- appl. township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> is n ,, tc, Qfria 0 ❑ Floor pl to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ EI @VatlOn O roperty <br /> ❑ PARCEL 0 Q JO` 7 �Z Liz 7�•-0 frontag n to scale. <br /> NUMBER / J <br /> TOWNSHIP: SECTION: <br /> 1A: 1/41/4: ❑ Drive p r . s <br /> ADDRESS: (stat , c u ty town) <br /> ss,��BDIVaJSION e. BLOCK/LOT Ti Sa '-ary permits <br /> CSM: LOT <br /> f'r 'r e Cree k --K (. . , private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 3 5 ea._5 O✓) 5e4✓l 1--0J1") ? ❑ Zoning iict r- c - <br /> ❑This project is a new building or structure. ❑ Permd Use? <br /> ZI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERV CE: PERMIT NUMBER: ❑ Rural Addreesss <br /> EWER nSEPTIC (new/e>�✓ ) <br /> HEIGHT IN T: ) - NUMBER OF STORIES: (Not including basement) <br /> r ; Cl Wetlano Fla <br /> Shorel:n. ( tta hment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ EfOSiO 1 permit <br /> //J 8 2.6-3_ 1_ TOTAL SQUARE FOOTAGE: j (slope ,cl ce, <br /> 2ND FLOOR: 3RD FLOOR: (( •/= filling CC SS) <br /> 2S 2 ❑ Revi: 1,4„t ".n Survey <br /> ESTIMATED CONSTRUCTION COST: and ; -i.:bl- options.♦ -a. ♦ ♦ —i. -0.. q5g <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes n No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? n Yes n No n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes n No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -i -o <br /> 545-112(4/08) <br />