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SUPPLEMENT to Web•App if <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 6////<L-SS 5. 4.6e F-.-"-.6 .,,(Lcz n Z• oning Status; CUP; <br /> OWNER A DRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> TO GTY 0 8/ 6Ditt-'4' LU.b Variance(# ) <br /> HOME PHONE CELL PINE E-MAIL ADDRESS <br /> Cp <br /> 4,fo q-USg7 n S• ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ S• ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> - <br /> PROPERTY/LOCATION INFORMATION (http:Uaccessdane.co.dane:wLus/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL v./..2.A,..5-0,7-,3.,.. A 1 <br /> EX,. // frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: YJ U SECTION: 30'. " l ' <br /> �7 <br /> 0/266o1.., ,sltii 1/: iv4J 1/41/4:446_6vril Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAE REM <br /> PROJECT DESCRIPTION: ` " F i <br /> . <br /> PO G 5A/6-47 LE��%o� I e mg <br /> 0 s1Fc _ _ ` . <br /> . ®This project is a new building or structure. -`K j " r a <br /> ['This project is an addition/alteration to an existing building or structure. - - ; <br /> SANITARY SERVICE: PERMIT NUMBER: -�0 ' <br /> fSEWER SEPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) � i6' k-f" _ <br /> 1 tiO1"_Ive eJ9apo® �, <br /> ta,A ;h R o R°titt$c1iment)' • <br /> AREA TO NEAREST SQUARE FOOT ; 1 `. fi: �r,. <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ��. '7� ' <br /> T sion.'°n o ..o ®µt3�-. ' <br /> BASEMENT: 1ST FLOOR: x" % ?`r <br /> TOTAL SQUARE FOOTAGE: .O,,-,,- <br /> -e o J [- aalncX� <br /> 2ND FLOOR: 3RD FLOOR:- 2 /C�,x/)! <br /> - V �/ �� <br /> si T .tf:39'� titio �f 1_ <br /> ESTIMATED CONSTRUCTION COST: ♦ --► --► ♦ -► --► $ `v O.O� O.r 01cj�` o o 4 <br /> (Please round to nearest dollar) ! x p- <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes g No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes FI No ®Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? FOYes . ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes EiNo <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 0 N 'Don't know <br /> 7. Is this to correct a violation? ❑Yes cerNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► .-■ -♦ <br /> 545-112(4/08) <br />