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-70 SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyo dane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> er-nciA rd T 1 09 S r.`/r/7 a Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> / Deed Restriction; CSM <br /> �7 sy /YI,��clVw U' ik, , / Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .20 . -510142 2./ -- '19D Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> V - .0 0 A' C tri. Site Plan including location <br /> AGENT ADDRESS CONTRACTOR Ai':-ESS of well/septic <br /> V ity,State,Zip) ( ,State,Zip) / Setbacks zi <br /> a 0 Fr 0 t-Jr re_ 4../,PHONE PHONE Site Plan approval from <br /> 5-7 c — 3 ' applicable township. <br /> E-MAIL ADDRESS E-MAIL••DRESS <br /> I c 1 'n_ i_4. 0,00 ntt loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: O s/ CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL G /b 7� d 1660_6 14- i 3.2, ?Y / s/ frontage drawn to scale. <br /> NUMBER / <br /> TOWNSHIP: SECTION: <br /> -1-10Wn D F fil i cid id-on as- 14: 5 E. 141/a: 14 E ❑ Drivew rmits <br /> �DDRESS: f (state nty,town) <br /> 7i-is-ii ,77eCt [L O� ie ll•I%�'7 eGf - ❑ Sanit. ■ •ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub' , ► ivate) <br /> / :; P(A,r)� Nvm <br /> PROPOSED PROJECT INFORMATION STAFF REVIEllf <br /> PROJECT DESCRIPTION: // ` <br /> S(.Y -h PO t i) I 1 X ,(Zoning Distr ` <br /> . Eiir This project is a new building or structure. Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. ' <br /> SANITARY SERVICE: PERMITN ER: Rfura '•, . qp <br /> ❑SEWER <br /> ^ ' <br /> SEPTIC 4\./ n eXl9ting) r <br /> HEIGHT IN FEET: NUMB O STORIES: (Not including basement) y , <br /> ' ❑ Wetl 1 dp*1.1- <br /> Shore (attacFtment� <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> C1 Erosio 7 • rot permit e <br /> BASEMENT: 1ST FLOOR: ' k <br /> j TOTAL SQUARE FOOTAGE: + (slope , • rbance, ,- <br /> ;2N . $ �. F� fiffing/acre <br /> 2ND FLOOR: 3RD FLOOR: . •--1-)1.' <br /> Q fevie t0on Survey, <br /> ESTIMATED CONSTRUCTION COST: ♦ --► --► ••+ ♦ _► $ "�- an 1 ble op ions <br /> (Please round to nearest dollar) �j—� ., u. .,',T4. <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 m 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? lA 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) ❑Yes 21 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 4 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —■. —► —► <br /> 545-112(4105) <br />