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. -F-n-yd-/C (d de <br /> ...... 00 C: <br /> SUFIPLEMENT to Web-App II <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME _ <br /> Q °`� a��e\ 0&'1 C� ❑ Zoning Status; CUP; 7f <br /> O W N E R Zi( _ ,� _CIS-AA, Deed Restric' , CSM <br /> �' -1 Street, U\ I-- V 4 V Q^' v6.,UJ Variance(# ) <br /> HOME PHONE" CELL PHONE E-MAIL ADDRESS <br /> .•— �' � ------ n Site Plan dra n scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes ' ensions <br /> AGALVT NAME CONS CTO NAME <br /> 1 Q f V\ �� �" L - 0K-e.,,, 0 J&,1\ n Site PI ' eluding location <br /> AGE�ITADDRESS CO RACTORADDRESS of well/s tic <br /> LY703 C4_ G CS 7 0; C��-Cr <br /> (City,State,Zip (City,State,Zip) , ❑ Setb ks <br /> N-\‘L� ) 7\ \ t . � to 1\ fo l i Li� -C3C37. <br /> PHONE PHON /� ❑ Site n of val from <br /> G 1 C163-635-2 jO�— q 3 S aPPli b wr hip. <br /> E-MAILADDRESS E-MAIL ADDRESS / <br /> -re C� J `j 6JV>,i . C 0v ❑ Floor plans to scale <br /> • PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CU NT ZONING: ACREAGE: <br /> ❑ PARCEL O%1� frontage drawn to scale. <br /> NUMBER v � 1����� d <br /> TOWNS IP: SECTION: <br /> C•f ,/4: ,/,/4: ❑ Driveway ermit <br /> ADDRESS: 1 (state, cou y, wn) V <br /> elOrs. —1 (f LCUI CSM: LOT SUBDIVISION BLOCK/LOT El <br /> sa ; egid Usli f 211 <br /> "vl <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW v tr <br /> PROJECT DESCRIPTION: <br /> Cis " C � J Zoning Distri ) 1 <br /> INThis project is a new building or structure. _] Permits Use? <br /> •. _Iteration to an existing building or structure. 4_-,, <br /> fl ral Address <br /> SANITARY SERVICE: PERMITNUMI ������ ( <br /> nSEWER ,��_ FTC ( !existin9) <br /> • crnRl S rNot including basement) <br /> ❑ Wetlan Flcpd ain/ <br /> Shore (a to hment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including jnfinished area, attached garages andrade decks or porches) <br /> BASEMENT 1ST FLOG _J ErosionControl permit <br /> �1c('�� v ,+, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> ).,Q CO iii�� � I. ' filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Gi <br /> Lilo li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ M and available options �% <br /> (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 M No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes rg 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# ) (I-ave blank if none) <br /> 6. Is a location survey required? (see reverse) )k Yes Tr on tyro w <br /> 7. Is this to correct a violation? •Yes �,]No <br /> 08) ��� APPLICATION MUST BE SIGNED <br /> (Continue APPLICATION Back) E <br />