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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NER NAME <br /> h/d/QmNY D/Q,n( lit'/ a ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Numb.er Street,Ci State,Zip) , / Deed Restriction;CSM <br /> (�7�5 /41/Pt/7 D -VX -5---3--- ? Variance(# ) <br /> }iOM PHONE CELL PHONE E-MAIL ADDRESS <br /> 08y9 6-36,RI‘.08)696- 63 c-rcW/pn 0 -id) //et ❑ 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 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://accessdane.co.dane.wi.usi) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> El NUMBER o 9 o 8YRsvo-3 A— to x 6/-5 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ,, C)/0C, X8-94/ '/:/1//r/.5174//41A: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 7 > y ? sOem6 /e/ -- <br /> _513 / ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> .: <br /> PROPOSED PROJECT INFORMATION , � r 71-':4— RE��" <br /> PROJECT DESCRIP ON:/r <br /> C/ 4Ou5//? 7C//77 � <br /> -ti-5 : <br /> . ❑This project is a new building r structure. -i - i�Q f <br /> Er This project is an addition/alteration to an existing building or structure. ` =. <br /> SANITARY SERVICE: PERMIT NUMBER: ' irli " rir <br /> FISEWER EPTIC 4 .,dal DIV <br /> HEIGHT IN FEET: 9;9 NUMBER OF STORIES: (Not including basement) - ` —'- <br /> or- e• rc me <br /> AREA TO NEAREST SQUARE FOOT: , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , . .- <br /> ? 0.w-,°atJ ? PILL BASEMENT: 1 ST FLOOR:, <br /> L-1) j TOTAL SQUARE FOOTAGE: j r6T F •1 - , ; <br /> f .. <br /> 2ND FLOOR: 3RD FLOOR: /�i�0 <br /> ( L ;—: 4 ,, F2: :—..- 6 0 tea-A.w .. <br /> ESTIMATED CONSTRUCTION COST: . <br /> (Please round to nearest dollar) --► -� $ 1 DDS GOO o � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes ©No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes El No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑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) ElYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? 2 Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► - —► <br /> 545-112(4/08) <br />