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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION .countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 61eue_Nt-J�kC qi-l& r =�c L leZoning Status;CUP; A I <br /> OWNER ADDRESS (Number,Street,City,State,Zi q Deed Restriction;CSM <br /> 9?-?-0 /U0 I UM`L'j Velnevki 10)-4-7 "535 l 3 Variance(# ) <br /> HOME PHONE CELL PHONE <br /> MAILADDR SS <br /> CIS- 3t 0 <br /> 0 C11.• 'eel'. ►j Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NA CONTRACTOR NAME , <br /> ertr� c\\ M��A�1 �° S��Gr1jut�C� Sit- ' • luding location <br /> AGENT ADDRESS C TRA'TO DDRESS • well/septic <br /> (City,Stat.,Zip) ❑ Setbacks <br /> (City,State,Zip) (City,5----A-, e 3 <br /> PA -� �' ❑ Site Plan approval from <br /> PHONE P •NE <br /> — q—SCt l 6 .1;—5i G l R((/ <br /> 0 applicable township. <br /> E-MAIL ADDRESS E-MAIL A.DRESS <br /> `. _ r c u 0 •N1 4 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) !...21- <br /> ' levation of property <br /> PARENT PARCFI NU C RR N ZONING: ACREAGE: p p y <br /> ❑ NUMBER 7o@313o, ' .A d 3,582., frontage drawn to scale. <br /> TOWNS k_iTION <br /> t .1/4: zes. ,/4,/4: 510 Driveway permi <br /> ADDRESS: sta - • I i <br /> ��0 Aja t �. Vc� <br /> �y I ' Gwp\��- ❑ Sanitary permits <br /> CSM: LOT I SUBDIVI*ION BLOCK/LOT sublic, private) <br /> oZ ` !Uvl , k <br /> PROPOSED PROJECT INFORMATION +.! <br /> SSA � °v SEW -` <br /> PROJECT DESCRIPTION: a ,� <br /> . This project is a new buildi or structure. �et,,� K ti o�'� lit- <br /> This project is an additio /alteration to an existin• building or struct r : , w <br /> SANITARY SERVICE: PERMIT UMBER: u "-t®° . _. ' <br /> FISEWER SEPTIC 4.c -pe -�,. ,1he <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ' 's . IZ;f ' <br /> / ;nom % ttt = <br /> r t S or an' - ini chment) f <br /> AREA TO NEAREST SQUA-E FOOT: ,- °� : ,-.37-1.,,------,:-- '' <br /> (Outside dimensions including unfinished area attached ga ages and above grade decks or porches) :h ,,0= <br /> � a fl" �e s . <br /> BASEMENT:11 L4 0 1STFLj}QO� i <br /> (jj�o��,,(( 4, TOTAL SQUARE FOOTAGE: °° , a , s"4C�x f; <br /> '?:414W11:.4?) A z +:J <br /> 2ND FLOOR: 3RD 3RD FLOO�R:/ ) �:� <br /> • �1 /�/"t�' J 1 1 F � -� a <br /> V ✓✓/\t to °` 1 <br /> �� er o <br /> ESTIMATED CONSTRUCTION COST: ¢ . -..ii a o t e <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ --► ♦ �VJ ` `;.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E ■o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes fa' Jo ❑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 'IQo <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 ., icTo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> 0/ � c APPLICATION MUST BE SIGNED <br /> / / ` - (Continue on Back) -+ -+ -► <br /> 545-112(4/08) �J <br />