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,SUPPLEMENT-toWeb-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER.INFORMATION .,.., _ ' . t. ,,-0. :.*:.-'-=,-,:---"..-.`-'-` ; 1 .` CUSTOMER TO PR VIDE <br /> t O NER NAME � <br /> 10��-1 Q( `J . f CI Zoning Stat ,CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) v Deed R rlction;CSM <br /> a9-nq e t,e ni u tau Rol (6mj4-0((r wL S3Sa3 Var' ce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS LI / <br /> /-. U / Ite Plan drawn to scale <br /> AGENT INFORMATION ;: `: CONTRACTOR'INFORMATION ` ; > '-a and includes dimensions <br /> AG NT NAME CONTRACTOR NAME <br /> 1kSSG(y'/is Fa W SGO o r M Site Plan including location <br /> AGENT ADDRESS c CONTRACTOR ADDRESS of well/septic <br /> LU`] ? CI Lo S(-ht �° rI. �� Setbacks <br /> (City,State,Zipp''')ll (City,State,Zip) <br /> PHONE P�t l . 1( son 1(,�J7- S-- .s ❑ ite Plan royal from <br /> PHONE PHONE ' <br /> I applic a township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS loor plans to scale <br /> PROPERTY/LOCATION'INFORMATION (httpd/accessdane.co.danewi.usl) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 1 frontage drawn to scale. <br /> NUMBER 02,-116712-333 -815-0 '` ` 2 (2) OTC) <br /> TOWNSHIP: SE O • 1 , t, '1 6 si Driveway permits <br /> PPc-c)■t,I '�4' W 1�4'�4' +v (state,county,town) <br /> ADDRESS: (�\ 0 I Q h ^ <br /> V� <br /> ' v Sanitary permits <br /> CSM: I LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION. - °' M <br /> PROJECT DESCRIPTION: r "� , <br /> ®This project is a new building or structure. 1,lif , <br /> ❑This project is an addition/alteration to an existing building or structure. i- <br /> SANITARY SERVICE: PERMIT NUMBER:.s�Q ' I31 <br /> ❑SEWER SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �` : -° ' <br /> AREA TO NEAREST SQUARE FOOT: r : A Y , Q <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ® ® i <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: � 4 at �, . : °b: <br /> y� <br /> 2ND FLOOR: 3RD FLOOR: - � G' A A ' .. <br /> €', � : <br /> ESTIMATED CONSTRUCTION COST: s <br /> (Please round to nearest dollar) o 0, 0 <br /> pond or lake? ❑Yes io 1. The property is within 300 feet of a stream or 1000 feet from a 2. Is there a wetland or floodplain on or near the property? L'es ❑Don't know <br /> ❑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? ❑ es No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) Di Yes <br /> blank if one) <br /> 6. Is a location survey required? (see reverse) Yes ❑ o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -0' <br /> 545-112(4/08) <br />