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v � <br /> 6 < SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> )1J L+ <br /> OWNER DR SS (Number,Street,Cit , t z �f=.j✓--t , ❑Zoning Stat ; CUP; <br /> Deed R st ction; CSM <br /> HOME PHONE 19 ?b CELL P' Variance ) <br /> HONE —, <br /> MAIL ADDRESS <br /> ti°`g` 3-3) • v-c- ' = LA- •i (... n'IA-k- ❑Site Plan dra n to Cale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes i nsions <br /> AGENT NAME CONTRACTOR NAME / , Site <br /> AGENT ADDRESS NTRACCT R ADDRESS � (S/rU cip,) ❑of wells incC ding location <br /> (City,State,Zip) (City,Sta a Zip) )14C14-- ❑Set <br /> PHONE PHONEE��� , t�l 44/ ❑Site Plan rfrom <br /> applicab towhstfi . <br /> — PP P <br /> � �S� 1 31v �, <br /> E-MAIL ADDRESS E-MAIL ❑ Floor plans tcale <br /> L R ici c. 11,:.._, ,ij <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation f operty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL frontage wn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> �p ,/. 1/1/. ❑Drivewa, oe <br /> DD 4' 4 4' (state, /.0 , own) <br /> ADDRESS: <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanit�l, <br /> (Pub c, ) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> qx-)(--._ c v7A 41\p1 ri°,1 D Zoning is 'et <br /> . ❑This project is a new building or structure. ❑:Permitted se? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural A( •S <br /> EWER �.EPTIC (newife g) <br /> HEIGHT IN FEET: 6 1 NUMBER OF STORIES: (Not including basement) <br /> l v(7 ❑ Wetian• ,i••,'L lei/` V Shorela • - to meat) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> 0 o Y 8•-rmit <br /> BASEMENT: 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: (slopes,'1' ®- Ce, <br /> v filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> loo a Rev" .®1,:n Survey <br /> ESTIMATED CONSTRUCTION COST: and v -•ie options." <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ Uc2 0 , 0(...1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes CEINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 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 toNo <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 ENo ❑Don't know <br /> 7. Is this to correct a violation? [Ives ,ZIINo <br /> APPLICATION on BacMUk)T BE♦ —►SIGNED <br /> 545-112(4/08) <br />