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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0104ER NAME <br /> Irnt.I a.. L - W o I4e.rt kg <br /> Status; CUP; <br /> O A4. J ES (Number,Street, ,State, • Deed Restriction; CSM C) ;1 Vd, � aYl and J to 3s5g <br /> Variance(# ) <br /> HOME PHONE CELL PHONt el E-MAIL p,p ADDRESS �'� <br /> V 44o 9.t 39 ,0g,4101 •O- 1 114 1Y Y0 Y,OLJ C 103 t ' ' 1 Ed Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [']'Site Plan including location <br /> AGENT ADD SS CONTRACTOR ADDRESS <br /> of well/septic <br /> (City,State, ip Q� i.0 (City,State, • MO <br /> 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 El/Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACR frontage drawn to scale. <br /> ❑ PARCEL O 1.,o -� 1(_ I' -k T' �( ACRE <br /> . g <br /> NUMBER lD <br /> TOWNS P: SEC ION: ❑N <br /> nveway permits QVtrt,V-1 1,: //: <br /> ADDRESS:,3C1 c, p � <br /> (state,county,town) <br /> 39 0 - / ���` (O L �S ❑ Sahitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: - 1L T ,EV1 It--� *[.,..,5„.,...:_ ,. <br /> his project is a nevi bu ding or star °o � <br /> This project is an addition/alteration to an existing building or structure. Y = 4 <br /> SANITARY SERVICE: PERMIT NUMBER: '0 .)t.. V <br /> s <br /> SEWER SEPTIC <br /> fI *M���A� ±f-', <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement)FI <br /> 20 1 ri.. <br /> Nor a r .` <br /> AREA TO NEAREST SQUARE FOOT: a rt <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) a r:v. <br /> BASEMENT: 1ST FLOOR: �� s F :fl . <br /> 3 x--12_ 4, TOTAL SQUARE FOOTAGE: 4, _, E� .x°-I�j°r 7 <br /> 2ND FLOOR: 3RD F1r00 ���� �- V <br /> ,n) � ,��a___ i 'ipl_ r=rilf:w4,..,.,,,;,-6„;-..,:wv, ":4:1 , <br /> ESTIMATED CONSTRUCTION COST: <br /> ♦ '♦ ♦ '� ♦ ♦ $ /3707 0 a ,, o-, Wi0:[- o o it <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? 1=1 yes MiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? urYes No El Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dyes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dyes ' No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# V ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑ es No El Don't know <br /> 7. Is this to correct a violation? Yes No <br /> APPLICATION MUST BE SIGNED <br /> 845112(4108) <br /> (Continue on Back) ■ -* -∎ <br />