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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ER NAME <br /> L 71 jrt El Zoning Status;CUP; <br /> OWNER ADDRESS Number,Stre City,State,Zip) Deed Restriction; CSM <br /> // <br /> `T<C217 ea,.'�?' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> L9)- )4011' y 89213 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> c 5 -v r 7 .j(¢ti aritr 7 ❑ Site Plan including location <br /> AGENT ADDRESS ( CONTRACTOR ADDRESS of well/septic <br /> 27 , a.ir j2E 'R ' <br /> (City,State,Zip) (Ci State,zip) [.� ❑ Setbacks <br /> PHONE PHONE <br /> 1 <br /> El Site Plan approval from <br /> ,069_ , ��3.? applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> . .� .e..-- ,-& . �� El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRE ZONING: ACREAGE: <br /> ❑ NUM ER (ig-ll 30 qTv f /: frontage drawn to scale. <br /> TOWNSHIP: SECTION <br /> tJ • r� SO/1) I� vk,l 34( ,/4. 1/11,4. El Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT 1=I (public, permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION " � <br /> PROJECT DESC IPTIO I ) _ vv z <br /> 6,4, 9a/b„.,.3.1 .-,, . , , : , <br /> . ❑This project is a new building or structure. - •t ¢ E«� 4 ; , <br /> 12 This project is an addition/alteration to an existing building or structure. -- <br /> SANITARY SERVICE: PERMIT NUMBER: A®° 'Y k <br /> •SEWER mi SEPTIC k <br /> HEIGHT IN FEET NUMBER DF STORIES: (Not including basement) , e1 om - <br /> _ yBFte 6 S 0 F. K x_ ; <br /> AREA TO NEAREST SQUARE FOOT: s <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) b� r'"i �ti a o cS'R �1 �� <br /> BASEMENT: 1ST FLOOR: � � � ` L <br /> 5-ra- n /a c/(� 4, TOTAL SQUARE FOOTAGE: 4, .�� r� _,, .g�-''�7 <br /> 2ND FLOOR: 3RD FLOOR: € � " <br /> /c0 0 k 4 � ' <br /> ESTIMATED CONSTRUCTION COST: /�/ dU €, d- ;, <br /> (Please round to nearest dollar) �'� �� ♦ ♦ ♦ ♦ `� ,, c2� � � ' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes El No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes ❑No ❑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? ❑Yes IE 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) Dyes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -4 -+ <br /> 545-112(4108) <br />