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� 0§ SUPPLEMENT ZONING PERMIT APPLICATION www.countydfdane.com T to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> J lmi 72At/j-j r) <br /> Zoning Status; CUP; <br /> O/WNER ADDRESS (Number,Street,City,State,Zip) �p <br /> / G / O V79-1-2-- 7) 9C{-,h&� PC.4-�� eed Restriction; CSM <br /> _ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> &5 22'V t58 , -4g6 U 2g Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME_\ CONTACTOR NAME <br /> uk-�Z.fu C.--0--&76 G2'�._ <br /> UtG..�� ,�-N �S7- bt,t./t-.6>., sP Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A RESS of well/septic <br /> Z'7 72 i 77 316 C 1''-e •�1.4(. <br /> (City,State,Zip) (City,State,Zi j4 Setbacks <br /> V C t.11 rRt4/) 1 / .5-,-?S-?O <br /> PHONE PHONE ❑ Site Pla pproval from <br /> f3 2--21>6---n applic le township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> S1�u,? ( ��.C11-. T6 • z(( Floor plan to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ` �Elevation of property <br /> PARENT PARCEL NUMBER: CURR NT ZONING: ACREAGE: /� P P y <br /> ❑ PARCEL �8 ) a ,�/6? D _ I 70C� frontage drawn to scale. <br /> NUMBER (310// / / ■ <br /> TOWNSHIP: SECTION: , ! <br /> S u rS /f'1 /3 1/4: )0 Go 1/41/4: N ❑ Driveway p rmits <br /> ADDR ES∎" (state,c nty,town) <br /> I O 6Z /PZ� - anitary permits <br /> CSM: LOT SUBDIVISION 1 u_/1 BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECTIDtESCRIPTION: <br /> p.4.1.)& 4i3 � v.,/ rC-i c. L, ❑ Zoning District <br /> . A-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 NUMBER: 0-'Rural Address <br /> LI SEWER a p/7r'3 3 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 't ❑ Wetland/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: f----, <br /> ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: Q <br /> /3 6O 1 C . ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ -+ ♦ ♦ -+ ♦ $ Oa 6e3 v, Dd and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 21No ❑Don't know <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? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes JO 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) DYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 2-No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► —► —► <br />