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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 /> -3 V∎S4)y` 1 3oknvk c9v1 ❑ Zoning Statu ' P; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> (0 �j(61 C01� 2":44-1�S D ed Re Iction; CSM <br /> an e(# ) <br /> HOME PHONE CELL P—HONE -( S E-M IL AGD�RGESS <br /> ) 4 . r '"6,o - 767-1f(c o 02 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Se I F Sit Ian including location <br /> AGENT ADDRESS w\& CONTRACTOR ADDRESS o well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Plan oval from <br /> applic a tow p. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ loor ns to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARf�CELNUMBER: C!CTIO URRENTZONING: ACREAGE: p t y <br /> ❑ NUMBER �I/° 67'°5b1-g( �� _� D frontage drawn t0 sc TOWNSHIP: <br /> jc vl. o"� (32-1-) 1/a: N Q 141/a: E ❑ Drivewa rmits <br /> ADDRESS: (sta ,county,town <br /> & / 6) 4. 7e-t- <br /> ❑ Sanitary •- its <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> .V (publi •rivate) <br /> :3 r <br /> PROPOSED PROJECT INFORMATION , .`F,,REVIIEYf -' <br /> PROJECT DESCRIPTION: ,, <br /> 3? 'X 5y ' 0 6,6..e_l 61 o.hra-cs e a ing District �` , <br /> ErThis project is a new building or structure. E Permitted Use?,';. <br /> ❑This project is an additio alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural '::,...t, S , ,, ' <br /> new ,. <br /> ❑SEWER SEPTIC ( t <br /> HEIGHT IN FEET: , NUMBER OF STORIES: (Not including basement) <br /> /6 3 ❑ Weti . oodplain/ <br /> -.reland (attactrme r <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Z, <br /> BASEMENT 1ST FLOOR: ❑ ECOSIOnpo• ;s @r17t1t <br /> / TOTAL SQUARE FOOTAGE: , (slope , °"[Stahl niter <br /> 2ND FLOOR: 3RD FLOOR:( fl ' •/ac p,p). <br /> 7 a g � <br /> ❑ Revie r k ocation Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options <br /> (Please round to nearest dollar) 61 600 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IgiNo ❑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 o <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 blan f none) <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) ■ —► —► <br /> 545-112(4/08) <br />