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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 ,, / 1 0 9355. It <br /> 1 �A7�6y/i SS A4A4 4O *Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 4 79 7 �D/f/!6 2G /✓, rnao/S141, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS . 370/-, <br /> ,Or- _21-6731e- T Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / l t 7-5° <br /> /� /(,S //1�fe - ,y' - • I' g location <br /> AGENT ADDRESS CONTRACTOR ADDRESS eptic <br /> /.5- 2 7 hz lA/s' /.‘ 3C 101/ <br /> (City,State,Zip) (City,State,Zip) Setbacks6 3 i <br /> r,�,M. �3S�S 7,6/. <br /> PHONE PHONE Site Plan approval fr m Nk <br /> 6®8- 76 7—, 70?9 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 04 Floor plans to scale ' <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) A Elevation of property-z,PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> D NUMBER C '/0-364 -9/8o C -i / frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> __3 _ /: -SE //:_ W_ 074 Driveway per ' k k <br /> ao 02 K-E <br /> (state,county,IVA <br /> ADDRESS: <br /> 479/ 17©.4av2 2/4,146• /�!-,i�isar, & 5370.i._— ,! Sanitary •-._••'ts tv A <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public • <br /> PROPOSED PROJECT INFORMATION prT277777477777171 <br /> PROJECT DESCRIPTION: <br /> '/flm G. 4_ S Qaa� iR4'4G� � ,� <br /> . QThis project is a new building or structure. 1� <br /> ❑This project is an addition/alteration to an existing building or structure. �'''s <br /> SANITARY SERVICE: PERMIT NUMBER: ``° <br /> ❑SEWER ❑SEPTIC Air r.,4151,41410,1* <br /> HEIGHT IN FEET: O , NUMBER OF STORIES: (Not including basement) <br /> iii,:'.:;a;1',.4-,-::: :-iIitg10::, <br /> QJ <br /> AREA TO NEAREST SQUARE FOOT: ititin.;!:21Zallital,(Outside dimensions including unfinished area,attached garages and above grade decks or porches) !I <br /> BASEMENT: 1ST FLOOR: <br /> -5a3� 1 TOTAL SQUARE FOOTAGE: $, , : 0 e °" <br /> v l <br /> 2ND FLOOR: 3RD FLOOR: .- � s � may, <br /> Y <br /> ESTIMATED CONSTRUCTION COST: $ d 78& i : , «. c �: <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ CJJ(O� �q <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ,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 '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) eXtYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ ■ -+ <br /> 545-112.(8/09) <br />