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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 /> 1 " t le OAeL )'Y 4 1Je Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ( 1 - I v,) 3 AJ �� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS ^ <br /> /t'∎i- 'atA YYI_ s - , 770_ ' rcom I e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e Plan including location <br /> AGENT AD R' S CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ks <br /> PHONE PHONE ite Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F or ans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) e <br /> evation of property <br /> PARENT PARCEL NUMBER: CURRENTZO ING: ACREAGE: P p <br /> El UmcsER nCt/04Lf 3-%er^ c p b- & frontage drawn to scale. <br /> TOW HIP:J ` I Slcrmo <br /> 15f 6 . y. .1\1 1/4/4.S)„..) ❑ Dr' - •ermits <br /> (- - -,c•unty,town) <br /> J ADDRESS/O , / <br /> (--_- / ) <br /> (_'` / w ' iN 1.-o,"--e.... IQ PM Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT '-'510v1-4,1 <br /> (�1 ( 1 <br /> (public,private) <br /> / <br /> PROPOSED PROJECT INFORMATION .,.;;STAFVArliI <br /> PROJECT DESCRIPTION: 7"°'` _ ,,.� ' <br /> ©s l ''E Ul∎-l6/A1g , J 'S/-1 RtS I o e :".1,:../"- <br /> . ,"This project is a new building or structure. s s` <br /> it . <br /> ❑This project is an addition/alteration to an existing building or structure. ' k�, . , , � <br /> Cam ,, <br /> SANITARY SERVICE: PERMIT NUMBER: (�//( r <br /> (SEWER EPTIC <br /> HEIGHT IN FEET NUMBER OF ST IES: (Not including basement) ' " <br /> 1S_ 1 i 4 e�e®F <br /> AREA TO NEAREST SQUARE FOOT: .-, .,: = t_ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) , . . `�z,_ <br /> j <br /> BASEMENT: 1ST FLOOR: ` eA e � <br /> 1 q /` q 4, TOTAL SQUARE FOOTAGE: l @ • <br /> 2ND FLOOR: 3RD FLOOR r <br /> I� at <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ M*.( 4-01-'11.-:',4' <br /> (Please round to nearest dollar) �-�k . <br /> 1. The roe is within 300 feet of a stream or 1000 feet from a and or lake? Yes No Don't know <br /> property rtY pond ❑ � ❑ <br /> 2. Is there a wetland or floodplain on or near the property? Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? cAqYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes VNo <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 r7 No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes El' o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -∎ -4 <br /> 545-112(4/08) <br />