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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWr ' v A ) <br /> y�y� �atAT �' ❑ Zoning Status;CUP; <br /> o E ADD SS (Nu er,Street,city,star z ) - q Deed Restriction; CSM�s G�i/✓Idt ,�/A C/ �/ - i��� / Variance(# ) <br /> HOME PH E CELL PHON E-MAIL ADDRESS <br /> - i9 9y3 GDt �%y5--Too /N :4,�I f ' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS <br /> E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL UMBER: CURRENT7�ONING: ACREAGE: <br /> ElPARCEL {p Q /r Cj frontage drawn to scale. <br /> NUMBER �/9O -p25/- '3 �— �C C X, ve. gO <br /> TOW SHIP: <br /> SECTION: <br /> �Q/J� 1/4: 1/41/4: ❑ Driveway permits <br /> AD RESS: //%% / ` (state,county,town) <br /> ��� �aU%'�� i/94 �� iz-, 51 0Z ❑ Sanitary permits <br /> CSM: LOT S BDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION R'/ <br /> . " �Tl1lF>l=REVIEW <br /> PROJECT DESCRIPTION: `` / <br /> je9° -1 71p .e/t G /'rc,/TvrA-( �«tcOr'c'' femme fL/ tnc : <br /> . ❑This project is a new building or structure. / � " <br /> El This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural ddress <br /> (SEWER SEPTIC nest <br /> HEIGHT IN FEET: �� ` NUMBER OF STORIES: (Not including basement) ae <br /> AREA TO NEAREST SQUARE FOOT: ' =., V <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ,„ , ,,,,.,.2.:,.77:l TOT.`.L SQUARE FOOTAGE: , ,,{ tt } <br /> _ ) <br /> 2ND FLOOR: 3RD FLOOR: f �IRg} <br /> n <br /> •4- s' <br /> ESTIMATED CONSTRUCTION COST: �- its o ' <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 [g No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes u No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 14 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 0 N ❑Don, <br /> t know <br /> 7. Is this to correct a violation? Yes ❑No <br /> AA BE SIG NE <br /> (Continue PPLIC on TION Back)MUST <br /> 545-112(4/08) <br />