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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AME <br /> '// A o fA- QS' r) A Wing Status;CUP; <br /> V OWNER ADDRESS (Number,Street,City,State,Zip) eed Restriction; CSM <br /> lig 11 Pe:g! /Za( f)rcicdil�,4.,: •S-6. Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> CQoa a 6 t Iwo Eil a Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Pl <br /> . an including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) etbackS <br /> PHONE PHONE ❑ Site royal from <br /> appli a wnship. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) E tlon of ro ert <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> ❑ PARCEL R-/A i / / rontage drawn to scale. <br /> NUMBER Q�O ES 35�-I �•SO(� �T E� I <br /> TOWN IP: SE TION: <br /> ,�/ S 1/4: s., 1/41/4: SJ' ❑ Drivewa ermits <br /> .J ADDRE1S�S: �1 Q (state ty,town) <br /> "1 � ) / r° , /� - _ ❑ Sanit er its ^ <br /> CS SUBDIVISION - - OT (J <br /> "�� �' (pub'' , rivate) <br /> PROPOSED PROJECT INFORMATION " F REVIEW <br /> PROJECT DESCRIPTION: ° <br /> K/d y /C( n a-P' S4�/. a I Tas <br /> . WI This project is a new building or structure. , <br /> I r 7! Se_-* <br /> ❑This project is an addition/alteration to an existing building or structure. 7 1 <br /> SANITARY SERVICE: PERMIT NUMBER: -o 1a0 e o re S ":*-.0,1, <br /> (SEWER SEPTIC 150 E . <br /> HEIGHT IN FEET: 9, NUMBER OF STORIES: (Not including basement) 4 `"t <br /> to - ,:e ,e . ®r aini <br /> �ryShor . . r ern#) <br /> AREA TO NEAREST SQUARE FOOT: '`V` <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) 1 ; , <br /> BASEMENT: 1ST FL OR: " o o 5- E yut o <br /> J / )1 0 , TOTAL SQUARE FOOTAGE: j •o` o - o <br /> 2ND FLOOR: 3RD FLOOR: t/ � -, <br /> sWo <br /> ESTIMATED CONSTRUCTION COST: Q /� e c�, - r i o <br /> (Please round to nearest dollar) �V �-� Q�-J W <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes p No ❑Don't kno10 <br /> 2. Is there a wetland or floodplain on or near the property? Dyes 2 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? E Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes M 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 E No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICAUST BE SIGNED <br /> (Continue on TION BacMk) -► -► -� <br /> 545-112(4/08) <br />