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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 /> `CAck Jkd L S/< < ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,Stale,Zip) <br /> A51a2i ( ga `e 4-.0.--4-t Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS, <br /> 4og 4711-o3Y8 aa-63� 1 lMAhk 5-k, se.4di44al./reerkv ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL MBER: CURREN ZONING:, ACREAGE: <br /> ❑ PARCEL 0709-�4 / 9 9- Q -6 3 frontage drawn to scale. <br /> NUMBER `E' ` <br /> TOWNSHIP: SE O <br /> 17 A oc irg.oI 1/4. J I� 1/x1/4. s ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 21 ec,dsev, k,-e cL 1t-c- W I 57 1.3 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION , <br /> PROJECT DESCRIPTION: 1 1 ,a // u ; <br /> Q n cJ o S%.11 (1 t. i t s .N1 r o t‘c,- . in" ,-- v <br /> This project is a new building or structure. v fir its s e ? <br /> ❑ P J 9 d P$nrt�t�Use? <br /> 14 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: a Rural 0;0 '''''T,� <br /> pq SEWER nSEPTIC (fIBw/4," <br /> HEIGHT IN FEET: /ii NUMBER OF STOFtES: (Not including basement) <br /> 90811} :, 4 att ]me <br /> AREA TO NEAREST SQUARE FOOT: , „ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: i r;10- �-(�, $ <br /> 4, TOTAL SQUARE FOOTAGE: 4, ,f + ftt51 y N <br /> 2ND FLOOR: 3RD FLOOR: s� ) tr <br /> a .. Su <br /> ESTIMATED CONSTRUCTION COST: (fir CO ri° o Ot{ ]S ;, <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ '♦ ♦ �J ,Vii, , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No El Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 9 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0 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 blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> ,..4 , <br /> .--- APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />