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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 <br /> b 1 Z Je ) 5f� f2J I er_ ❑ Zoning Status;CUP; <br /> OWNER RESS (Number,Street ity,State,Z `/ /L, Deed Restriction; CSM <br /> 111111 AD 11 y / Variance(# ) <br /> HO E PHONE CELL PHONE / E-MAIL ADDRESS <br /> ,,d s7(6 .51" 93 9�7 ■*Z ' CZ D 4— ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR ME <br /> j� I ± ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR 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://acc:essdane.co.dane.wLus/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: <br /> ❑ NUMBER 09b `d �a� 2� �C, 3 frontage drawn to scale. <br /> ;1 � ��5 <br /> TOWNSHIP: SECTION: <br /> .k-} y� '/a: '/4'/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> /62 Hy 1/ ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION , AFF <br /> ' f PROJECT DESCRIPTION: ti , <br /> C%%0 C,I,� • o., <br /> ®This project is a new building or structure. �i et ; <br /> ❑This project is an addition/alteration to an existing building or structure. ,' <br /> tructure. `0 <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rur .;:y.x ess <br /> RSEWER SEPTIC z (ne'ilvie't tg);- <br /> '`./'7"' „ <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3 f Wetted �Plair!�� ';Shore {�chm <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �� s � <br /> >< / + TOTAL SQUARE FOOTAGE: j 'f +e'''';4'''61'.1 ^��, <br /> ]� 6 �ngta s) <br /> 2ND FLOOR: 3RD FLOOR: F.‘c/ taRe <br /> ESTIMATED CONSTRUCTION COST: and avaable c� ` ��" <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ —. ♦ $ �O16 ZI ,,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo El 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? NI 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 174No <br /> LP)/ 114d APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />