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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 /> C(CJ Cr t igAro'� ''1 <br /> a f r <br /> ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip Deed Restriction; CSM <br /> M 91-) RITYinr\4- V iCl. C,c1. %16(1/ 4L ) l)I Sz?5- <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> IA-1 C) -33)4-7 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR``INFORMATION and includes dimensions <br /> A9 T NAME I CONTRACTOR NAME •L,C11)? NC(,r\Gp((, C4( ;ht,4-,j �,L.. ❑ Site Plan including location <br /> / <br /> AGENT DDRESS CONTRACTOR ADDRESS ) of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> p1-10N PHONE ❑ Site Plan approval from <br /> 6 Q <J c f -5crA G( .DDS-- C J applicable township. <br /> E-MAIL ADDRES E-MAIL ADDRESS <br /> —_� 111 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.Oo.dtane:wi.us/ : ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL ci _I"I M-. A i (E�(> [ f frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> \I 14 1 b '/: W 1/41/4: ��g ❑ Driveway permits <br /> 11�(�©('�� (state,county,town) <br /> ADDRESS: 1 _ <br /> 9TB \Ie W 1* On vlLL . r�a�� GCAI., ux s-)1. ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION "41 STAFF'REVI `- <br /> PROJECT DESCRIPTION: )) ) \ ,\ ] 1 1 ■ .. ,; <br /> LV1�5loor.!rnA C('>h / (p0c6Ft GUCI, h41, 'Oin7ile D g:r € _ ' rv& - <br /> y <br /> • ❑This project is a new building or structure. a;. � . §.� - <br /> Ji1 is project is an addition/alteration to an existing building or structure. '' 4 <br /> SANITARY SERVICE: PERMIT NUMBER: R; o o .4 <br /> (SEWER [PTIC ` <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) �f <'- `-� .'=" "'f - <br /> 9/ 1 etlan a o o <br /> ;.-4Iaore a . Y b <br /> AREA TO NEAREST SQUARE FOOT: -t - T h <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) l r r , <br /> 7.BASEMENT: 1ST FLOOR: T--.. t�op e o <br /> 1 41 f 4, TOTAL SQUARE FOOTAGE: 4, riN, O d <br /> 2ND FLOOR: 3RD FLOOR: c ;• <br /> ESTIMATED CONSTRUCTION COST: �� Q� *'q`` 01-(741;o a?e <br /> (Please round to nearest dollar) ♦ ♦ --► ♦ ♦ ♦ _, <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 0 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 ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i 4 -► <br /> 545-112(4/09) <br />