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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 /> _ LOP/AN Ce1.1 Pre A/ ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number.Street.City,State,Zip) Deed Restriction; CSM <br /> 7/051Fecv2 y /el.v/ i/1602/.4i t /. S'.3 f7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAI ADDRESS <br /> BPD'-g33-/g i ' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CON RACTOR NAME <br /> f6,4 5 //I/e_ ° ❑ Site Plan including location <br /> AGENT ADDRESS CON RACTOR ADDRESS of well/septic <br /> / 2 /la'y /¢ <br /> (City,State,Zip) (City, •tate,Zip) ❑ Setbacks <br /> 15)Z •GK- 4;94 r i, 4%. .S' 5",65 <br /> PHONE PHO E ❑ Site Plan approval from <br /> p,g-76 7-.? 70� applicable township. <br /> E-MAILADDRESS E-MA LADDRESS <br /> 6/4.an Om e s-.41),(04-. ce ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpd/accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CUR'ENT ZONING: sLi0 ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL p 3 frontage drawn to scale. <br /> NUMBER +'s6 -Dflc9fJ-/S3£�rv�l /� H—� <br /> TOWNSHIP: SECT ON: ❑ Driveway),R/N6 Fib e4 _—/ __-- %: 5 Vv 1/1/:_AN__ y permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> /dSe9 q S (public, private) <br /> PROPOSED PROJECT INFORMATION ; i Itt <br /> PROJECT DESCRIPTION: / i , <br /> . �P■ This project is a new building or structure. , , ': <br /> ❑This project is an addition/alteration to an exi ing building or structure. t',ii <br /> or p <br /> SANITARY SERVICE: PER IT NUMBER: r *V <br /> ❑SEWER ❑SEPTIC , ( ; 4j. < <br /> HEIGHT IN FEET: , NUM:ER OF STORIES: (Not including basement) <br /> 2.3 AREA TO NEAREST SQ ARE FOOT: 9r� V <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) _ <br /> BASEMENT: 1ST FLOOR: 4117 i � �m , <br /> 4, TOTAL SQUARE FOOTAGE: 4, 5 a a° S. ce <br /> 2ND FLOOR: 3RD FLOOR: d Sad T, ' , <br /> s6 ury T <br /> ESTIMATED CONSTRUCTION COST: -► ♦ i. <br /> (Please round to nearest dollar) Q 78/1 arc <br /> 1. The property is within 300 feet of a stream or 1100 feet from a pond or lake? ❑Yes 'No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the p operty? CI Yes ANo ❑Don't know <br /> 3. Have you talked with the township about your p oject and are they in agreement'? aYes ❑No <br /> 4. Has there been a zoning permit issued for this Droperty in the past 5 years? ill Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/va iance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes arNo ❑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 />