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SUPPLEMENT to_Web•App it <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA / [[ �/ <br /> VQ 2/ �7o�OO Ill 5fi n Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Str:et it,State,Zip) g <br /> cj / �J 54 �14 Z' 5-f5��t Deed Restriction; CSM <br /> 37�, ^ a v� fay 5 / Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6ai-7.11-4/ 6 /r2..f�O Po©a te•f e--coin . ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION '5 and includes dimensions <br /> AGEN,Tf�AME / CONTRAC O NAME <br /> �/b0 Ze-_, c/ecA j/4. n Site Plan including location <br /> AGENT ADDRESS CONTRACTOR AD ESS / of well/septic <br /> a2 / �-,o9��a ,Q,,, - /9U ,/. J <br /> (City,?late,Zip) (City,Statp,Zip) ❑ Setbacks <br /> th4 11- /n/`? V,i , r0.-F .555• . <br /> PHONE PHONE n Site Plan approval from <br /> ,4 77z25 .U,;�Y5-2 7DD applicable township. <br /> E-MAILADDRE4/eci E-MAIL DRES.64.,/ '�si . / dzz�(©e lac,,, A�.1�,,, ,,„,44 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpa/accessdane.co.danewi.:us/) , ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACR GE <br /> ❑ PARCEL 0 G1 I 0 – ��f_SI Osa,o k f h ' frontage drawn to scale. <br /> NUMBER `(�-� <br /> TOWNSHIP: SE 0 <br /> TOWNSHIP: ./1 q ,/: Al /4,/: jl� El Driveway permits <br /> ADDRESS: 1 / v (state,county,town) <br /> Lle,-. l ,./�-�� ' °'� e'f�, �- ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> L A <br /> + (public,private)ill I <br /> PROPOSED PROJECT INFORMATION .5110.Atec-Stict.PREVIEW. ` <br /> PROJECT DESCRIPTION: « x'- T 44 <br /> . This project is a new buildin or structure. ,_� 75,z mow; <br /> El This project is an addition Iteration to an existing building or stru ture E�` � . ". <br /> SANITARY SERVICE: PERMIT NUMBER: rF1' ®o x <br /> nSEWER EPTIC :1 - 4),: ,�® - :' <br /> HEIGHT IN FEET // NUMBER OF STORIES: (Not including basement) 4£'= "w g <br /> ttx bore an a r <br /> AREA TO NEAREST SQUARE FOOT S u <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) 1 .` G <br /> BASEMENT: 1ST FLOOR: TOS{f1 "o n o e{I r "'- <br /> 4, TOTAL SQUARE FOOTAGE: 4r ! "Oee el Ireanc �� <br /> 2ND FLOOR: 3RD FLOOR:" c <br /> /fiD . s i�` tarp <br /> ESTIMATED CONSTRUCTION COST: i <br /> (Please round to nearest dollar) r �j r�� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [ N ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Y L�J'"o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ffYes ❑ • <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 blank if one) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑Don't know <br /> 7. Is this to correct a violation? ElYes [VIVO <br /> APPLICATION MUST BE SIGNED <br /> /". ( (Continue on Back) -0- -0- -0 <br /> 545-112(a/os) <br />