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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER MI ME <br /> vVti irn i-• R.1 ID Zoning Status; CUP; <br /> O ER ADDRESS (Number,Street,City,State,Z l) Deed Restriction; CSM <br /> 4lO02 ' Rip -)r ; VP Variance(# ) <br /> HOME PHONE • CELL PHONE E-MAI ADDRESS ( <br /> r 8-9/1 r. V S.. -,_ `1'Q S : . P t ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> �00 . )04 r aX1 LLC �ros . ❑Site Plan including location <br /> A y IDRESS J TRACTOR ADDRESS of well/septic <br /> GG• efr fie, do &i ck/ oacr <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE / ❑Site Plan approval from <br /> 14$ -85-0 •S 78 1 -Y00 -46.S-103o applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tr i G : ds -h p f ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT TING: ACREAGE: /,f <br /> ❑PARCEL <br /> UM EL OTOS ,3to 1 4003-0 P62 - 7 G 7 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SE/C114: <br /> Ike 3 ': � '/%: /it-- ❑Driveway permits <br /> AD ESS o (state,county,town) <br /> CO°AI( kill ' r ic"kt , WJ S3So�9 <br /> LOT SUBDIVISION BLOCK/LOT El Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIO <br /> ,5 kop ❑ Zoning District <br /> . This project is a new building or structure. <br /> LI Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: � !�'^� PERMIT NUMB: ❑ (new/existing) <br /> EWER EPTIC n� /.3 _p2 1S_0 O�O D <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 1Metland/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: 1--1 <br /> ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: p filling/access) <br /> 41/ 33g. " / ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ �qc/ 400 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes gNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes MNo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? IgaYes 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) ❑Yes '' o ❑Don't know <br /> 7. Is this to correct a violation? Elves po <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ <br /> 545-112(4/08) <br />