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SUPPLEMENT to Web-App <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ZA `L n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 6'7 22 i,J,.,,d(s.-- Cokey Li.-c__ Variance(# ) <br /> HOME PHONE CELL PHONE <br /> E-MAIL A ii DRESS <br /> 6a.- $`'f- gips' 6(A- 5i3.29kei M' 'vckll? ' ,vt,, ( co n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> /44c-4-11,<,„) Kie.h,l i.-c... u; 7r.y-1 e.. x _ Site Plan including location <br /> AGENT ADDRESS CONTRA TOR ADDRESS U of well/septic <br /> 5`il6 it St Lack -)._2_1-1-2 /•` tJ <br /> (City,State,Zip) (City,State,Zip) v, 4rl� / fI Setbacks <br /> PHONE PHONE n Site Plan approval from <br /> 60 C- 5/3 zg�+9 G(-- 22-Z - s 3 ; 3 applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> K,4._.‘,,\ r? @ �,> (f, n Floor plans to scale <br /> PROPERTY/LOCATION II±FORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> 0 PARCEL 061(0-245-0502.---0 12-1 „Cs`c ( frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> W 14Car . '/a: INN: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> G7 2 2. W■.,.ek- (.z.,...a., <br /> H Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . his project is a new building or structure. ❑ Permitted Use? <br /> H This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVI E: PERMIT NUMBER: ❑ Rural Address <br /> SEWER nsEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 066-b1 (.311 5 74, ❑ 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 /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> (i‘jc- :IS I yI 1�Y ,, TOTAL SQUARE FOOTAGE: 4. (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: l O filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: C and available options. <br /> (Please round to nearest dollar) ♦ ♦ --► ♦ --I. ♦ 4 C; C; <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes n No Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes E No n 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 n 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) n Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes nNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0 -0 -0 <br /> 545-112(4/08) <br />