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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 /> Ke--t 4.)k R - lie n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> t57 sO y �U ietsv e_, _ SON ?tf,(e .yJ1 s3s9.© Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (00%. '7S—49%1 S/!-kE ye1t •,C^"}"l�_ P• C <br /> 1,10L, r'vNet n Site Plan drawn to scale `� ( <br /> AGENT INFORMATION CONTRACTOR INFO RMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> V ❑ Site Plan in ud" g location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> r <br /> c. — <br /> (City,State,Zip) (City,State,Zip) El Setbad s` <br /> PHONE PHONE ❑ Site Plan a;.ri)G ern <br /> applicable ii , .h •. <br /> E-MAILADDRESS E-MAILADDRESS <br /> . ,.•■•■■_ ❑ Floor pla tS scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wius/), ❑ Elevation of rop <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE <br /> ❑ NUMBER 05$/0$11-171-3Floo'O GI 12-31 O. 3% ( frontage dra o scale. <br /> S) <br /> TOWNSHIP: SECTION: <br /> ,/: 1/41/: ❑ Driveway permits �,.r <br /> SvN Qr�,�r� (state,county,town) <br /> ADDRESS: <br /> 5-no ? -meuJ .1,0t-i 3 u 1)1r-extrt-e ( S3 S9 O ❑ Sanitary permits /�CSM: LOT SUB !VISION BLOCK/LOT A (. i <br /> (public,private) 'U i <br /> PROPOSED PROJECT INFORMATION W OWEV � <br /> ���STAFIF�REYJ <br /> PROJECT DESCRIPTION: y`s' = ":.' '4: _' <br /> c.,, 41 I .a,�cal 1, 3 a ; *4,- ® s i , <br /> • 1 ' This project is a new building or structure. a -.°�,a m afla <br /> El This project is an addition/alteration to an existing building or structure. r� 7. <br /> SANITARY SERVICE: PERMIT NUMBER: ba "d 9 S .- 4.k.s <br /> SEWER 154SEPTIC -i- � <br /> HEIGHT IN FEET:, NUMBER OF STORIES: (Not including basement) -0 � - 1 r. it <br /> , fie �s e� e <br /> AREA TO NEAREST SQUARE FOOT:.,„` :? 7 ,o <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) " <br /> t7SI . o a r o is <br /> BASEMENT: 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: 4, - O 6e r,'.°_I ``lX� "`. <br /> 2ND FLOOR: 3RD FLOOR: 7 :-F) f , -^ , <br /> '- nit- y '�'�'�.tf i."4f- folijir : 7 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ( t+€� nrT)r1 6:T i e` ° `` <br /> (Please round to nearest dollar) N -1,. .--.- <br /> i I <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 2 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? ❑Yes XrNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#Of Lf ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correcta violation? ❑Yes Dg No <br /> A-161L a APPLICATION MUST BE SIGNED <br /> ` (Continue on Back) -i -* —► <br /> 545-112(4/08) <br />