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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> as 19 S-co <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /2dreoal U//2a/ L__ .° 0/2 /3reW/2<9 ❑ g <br /> Zonin Status; CUP; <br /> OWNER ADDRESS (N er,Street,City,State,Zip),r� /,, /// C Deed Restriction; CSM <br /> 7pil99 (a it-/-ow /`�C�! . !/��/ G�// —�.SSJ Variance(# ) <br /> HOME PHON CELL PHONE E-MAILADDRESS <br /> ��� C�- E',-�// y -S9 2SAr7. b"E'e://2/". o/�iY!/�0 Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .$ nib' aS- (.b9ve, '� 4p--S � --e_ ❑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-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CU RENT ZONING: ACR E: ❑ Elevation of property <br /> ElPARCEL 3 ) 6 - 9 frontage drawn to scale. <br /> NUMBER ( O� � o�3�U <br /> TOWNSHIP: SE TION: <br /> QXbt/tY 1/4: ,/4,/4: ❑ Driveway permits <br /> ADDRESS: <br /> 1 '7Z-- oe//-e /e d <br /> (state, county, town) <br /> ❑Sanitary permits <br /> CSM: (5'1'44 LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> s <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �L <br /> � C /7 7'7 '�/ ❑ Zoning District <br /> . This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER. ❑ Rural Address <br /> FIEWER j/SEPTIC k , /5—©°° / (new/existing) <br /> HEIGHT IN FEET: /)( NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ <br /> BASEMENT: 1ST FLOOR0 : <br /> ErosionControl permit <br /> 3 3(P-6/Co 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ,S—D09( f filling/access) <br /> f r ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ c 3 ,,,,,\ and available options. <br /> Please round to nearest dollar) t iV v CJ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes go ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes fNo [V]6on't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'Wes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes to <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 26on't know <br /> 7. Is this to correct a violation? EYes [ K° <br /> d71 Lj D APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />