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C ,aAx . a1S4- Q= St'1G <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION .countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME o � T �� roc w Are/ /sz_F ning <br /> Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 73W /11//?-7114 ? t] S TtJR P"rY s 3 c 3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 3_ ff 30 7 39 3—le 3 G ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> c(q-G G e-- �/-5 e e e-o-�,- , ,c OCJ�Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> .5-Ye y'!'.9,-70 .s <br /> (City,State,Zip) (City,State,Zip) LM 5eibacks <br /> �9v,e L � 4/1 S3S83 <br /> PHONE PHONE ❑ Site approval from <br /> yj'. /.0 77 ap a e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> � ze- r ���6'u"e, / �� Yee,e,� oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.clane.wi.us/) ation of property <br /> PARENT PARCEL NUMBER: CU RENT ZONING: ACREAGE: <br /> ❑ PARCEL LL// frontage4rawn to scale. <br /> NUMBER ��U 7-/4 Z,.yeeo.. 5, 7�, <br /> TOWNSHIP: SE TION: <br /> ,� ��y '/a: 11%.J %IA: S , Driveway p its <br /> -ADDRESS: (state,county,town) <br /> 139 ' /,t,y g /77 S4kix Zit,, w/ $3SQ-3 anitary permits <br /> CSM: LOT SUBDIVIS ON BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION rSTAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> �/ 9 <br /> ,t/6/,/ /e/6 iue' l'o,✓Sr.�' ro.✓ G ear- pvJ fi ning District ; <br /> This project is a new building or structure. <br /> ermitted Uses; <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NJMBER: alAddreS.S, 0 <br /> ❑SEWER SEPTIC .Sc2 0399 (ne '' - ., n' t 0 ; <br /> IN FEET: NUMBER OF STORIES: (Not including basement) ` <br /> v-11EIGHT - � ❑ Wetla�i�/Ft:•�d�latn�� �,1/4c�./9 Siorrj (attacimsen <br /> AREA TO NEAREST SQUARE FOOT: t � ' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) a,,. <br /> II BASEMENT: 1ST FLOOR: ��� rOSIOWf1 1a� grr® <br /> / 7 6o G 4, TOTAL SQUARE FOOTAGE: (slopes,disturb tnce, <br /> yU r'-'" fl f r .lac ess) <br /> 2ND FLOOR: 3RD FLOOR: �, rt ': <br /> (l Review L+ca : ' Survey <br /> ESTIMATED CONSTRUCTION COST: nd ava 2, @ utons <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 'lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes la No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? )3Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes x2No <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 /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -P <br /> 545-112(4/08) <br />