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• <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 646 G if..Z.5 K <br /> ❑ Zoning Sta ;CUP; <br /> OWNER ADDRESS (Number, City,State,Zip) 4,r-- Deed riction; CSM <br /> HOME ONE / CELL PHONE &E-MA Aio ADDRESS 11,464 c7S- Va • nce(# ) <br /> -II3 -ILI O (OP-L9 c-' /? S 7 Z Y* ' \ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS /�1 ,� CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zi5 /Y"-Z C- (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan royal from <br /> applic a township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floylert s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL MBER: CURRENT ZONING: ACREAG ❑ Elevation property <br /> ❑ PARCEL 0 / / 'S�(i_172. 2s33,o R_ 2._ <br /> r fronta drawn to scale. <br /> NUMBER I `�, <br /> TOWNSHIP SECTI <br /> P� Rr 1/4: N w 1/41/4: NW ❑ Drivew permits <br /> ADDRESS: (Stat ,county,town) <br /> /0797 fvf/4Giur7v 0 t'- 4'461 w 33c7Z- ❑ Sanita permits <br /> CSM: LOCT — .3 1BDIVI5I0N. ,- , BLOCK/I�OT <br /> SSIV // (pu 'C,private) <br /> PROPOSED PROJECT INFORMATION i1STAF;F 80,04, fr>q <br /> PROJECT DESC llla <br /> F, , oning District <br /> ❑This project is a new building or structure. ,.Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> ❑ Rdral 'jdre <br /> SANITARY SERVICE: PERMIT NUMBER: ti <br /> ❑SEWER „SEPTIC (rye exis tn+ �� <br /> HEIGHT IN FEET: cr NUMBER OF STOTES: (Not including basement) <br /> STOTES: Wetland/ •odtl1n! <br /> AREA TO NEAREST SQUARE FOOT: ShoC nd (attaChrnent <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) r <br /> BASEMENT: 1ST FLOOR: ❑ EC(3S1Qnf?It er ti <br /> 1 TOTAL SQUARE FOOTAGE: 4, (Slopes rue,- . <br /> 2ND FLOOR: 3RD FLOOR: filling/a� ess) <br /> 2, 7LI <br /> Review Laeation SurVe <br /> ESTIMATED CONSTRUCTION COST: -, -9► --► and aV !{akf(e , tfCns <br /> (Please round to nearest dollar) $ •9 t7 , „ 14 . . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes liallo ❑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? 0 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) ❑ es 52 No ❑Don't know <br /> 7. Is this to correct a violation? es *No <br /> \f(i-S <br /> /(i/ APPLICATION MUST BE SIGNED <br /> ( (Continue on Back) -► -► <br /> 545-112(4/08) <br />