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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN tyA E y �Ll <br /> ��1lll El Zoning Status;CUP; <br /> OW ER ADDRESS (Number,Stre t,City,State,Zip) W ��! /D Deed Restriction; CSM 0.;sy &.'<ilie Lc' �,t elZ�..^c' J6 Variance(# ) <br /> HOME PHONE CELL PHONE p E-MAIL ADDRESS <br /> :K*613g_SS,9 7 i'3 -5587 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> y' - S c,w,e G s Cn/ - <br /> El Site Plan including location <br /> AGENT ADDRESS •NTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: / CURRENT ZONING: ACREAGE: <br /> 1:1 17M G)b c)6 02 2 i S-3 U G) (� I 1 •. ?) 7 7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 0) 1 1 t,�, ❑ Driveway permits <br /> i\4.‘, z o vvtC 11 Z /4: /�/ /"/°: N I (state,county,town) <br /> ADDRESS: If <br /> 6 L$ `-( L (1t� L ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 0 b 4 '1 2, _ _ (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT ESC IPTION: 4,;;Oi r `' <br /> . @C This project is a new building or structure. C•Permitted Use% <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: , ) ;°;" �'" <br /> fSEWER SEPTIC #'! " �g <br /> HEIGHT IN FEET: / q i 3 p NUMBER OF STORIES: (Not including basement) j <br /> ,. € s s t;i':r,.,'7,f � <br /> AREA TO NEAREST SQUARE FOOT: " <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) , " {0 j t . <br /> sionContror <br /> BASEME7 1ST FLOOR: J " " rb <br /> / a i Q j TOTAL SQUARE FOOTAGE: 4, " F, " <br /> 2ND FL 3RD FLO <br /> /280 '''!., y, <br /> Review 'f.-1.P.-7--,''t:° , <br /> ESTIMATED CONSTRUCTION COST: 0 ��,ada�i 1 <br /> (Please round to nearest dollar) j (�Gv ;�/ ., -, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes .12it'•o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes El No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? _®Yes El No <br /> 5. Is this project associated with a rezone/CUP/varialce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ales , No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes EiNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ■ ■ <br /> 545-112(4/08) <br />