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D - 675-1a6 <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION winrw.couriyofdane.com . <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ,,r'b�c�)c.P.v <br /> �O >nl cl- I 1 GK 1 oning Status; CUP; '�„ <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM "e1/ <br /> r L46 7 '� V es oTvN Variance(# `) <br /> \ �AY19 e. e <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Gd$`57� L 33a Ite Plan Iran t scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includl dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> l' il RM A36oC i 4e4 WIC. Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> �a Bo 501 e,�r R;t e c�f.,b - / <br /> (city,State,Zip) (City,State,Zip) etbacks Y <br /> Ve orIc.� I 635 �(' <br /> PHONE ONE r ❑ Sit- PI. -••'�4, al from <br /> (00i. - 575' 0373 a.. bI= • n.hip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS `Lk:M C..1—Z1-46.11 P - oor pl s to scale <br /> r-- <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) vation of property <br /> PARENT PARCEL NUMBER: CURRENT Z ING: <br /> ❑ PARCEL �, r,�ry.� g; ,- le , frontage drawn to scale: <br /> NUMBER - O� G� � n Mall <br /> TOWNSHIP: SECT ON: ,�,,pp ' ■ <br /> , i0, r 1/: V4_6 1/h: C riveway permits • <br /> ADDRESS: (star" nty,town) <br /> CSM: Y / LO£ SUBDIVISION _BLOCK/LOT (pub(p ,private) A <br /> PROPOSED PROJECT INFORMATION ea g 4 V. ,.e.. <br /> PROJECT DESCRIPTION: 71 r, ix ,, <br /> le?l6ec bvrnap �omc * ,•nin• D s� � <br /> . ®This project is a new building or structure. " N;.„ <br /> ❑This project is an addition/alteration to an existing building or structure <br /> '°, �� <br /> SANITARY SERVICE: PERMIT N BER: - ° .� ° " <br /> •SEWER ri SEPTIC G57 -4,400%00,e sv <br /> HEIGHT IN FEET NUMBER OF STO- S: (Not including basement) �'°'- �^ 1 ' <br /> • AREA TO NEAREST SQUARE FOOT: ° ";_ ,,,, <�--: <br /> (Outside dimensions including unfinished area, attached ga-ages and above grade decks or porches) - . .� <br /> l:i( o a,a o €o1) i E . ;' <br /> BASEMENT: 1ST FLO L •s •liu�® p <br /> 4, TOTAL SQUARE FOOTAGE: 4, �° . <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1 os <. <br /> ESTIMATED CONSTRUCTION COST: T a .1---6•Vii• , <br /> (Please round to nearest dollar) ,,.. ` - .��.. <br /> 'I <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 ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dyes ❑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) Dyes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue B 4-4. —0- <br /> 545-112(4/08) oeed r <br />