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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 /> i <br /> • Q u7"h d us e f--o rm L i,C l Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> .sly - c(oL, vity Road A ariance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> eff8835--.sxc'7 6,9? 60 0?9 s Donkeys-e fai'ryi L!ti 0chcerTA014t ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Plan royal from <br /> applic a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) I=1 Elevatio property <br /> PARENT PARCEL NU BER: CURRENT NING: ACREAGE: <br /> ❑ NUMBER O'S O S 1 -'Q© ©© 1 ' E X . 7 fronts drawn to scale. <br /> TOWNSHIP: SECTIO <br /> © ,ce Q n a ,/4, N FL- ,/4,/4. s j� ❑ Driv wwa ermits <br /> (stat ounty,town) <br /> ADDRESS: S / z C 0 V >) ,i V 1 a <br /> CSM: LOT SUBDIVISION BLYK/LOT ❑ Sanitary rmits <br /> (publi , private) <br /> PROPOSED PROJECT INFORMATION v STAFF REVIEW <br /> PROJECT DESCRIPTION: /J �` <br /> IP <br /> Sw (I - Ba f n �"1t G Q Zoning District <br /> ❑This project is a new building or structure. Li Permitted Use? <br /> ❑This project is an addition/al eration to an existing building or structure. ( <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> n V SEWER EPTIC r (new/e(�ISting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �--�:% <br /> W LS (9 0 e Li Wetland/Floodplain/ <br /> - Shored (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) [-t / <br /> BASEMENT: 1ST FLOOR: ErosionCo of permit <br /> Iii 31-1 X 66 4, TOTAL SQUARE FOOTAGE: 4, (slopes, sturbance, <br /> 2ND FLOOR: 3RD FLOOR: fillinccess} tAN <br /> ❑ Review Location Surve� v <br /> ESTIMATED CONSTRUCTION COST: and available options.-1. -o. -1. -4. .-ii. $ Z/ O O O(Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o El Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es 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 ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan 'none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />