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:::7 `1/4 SUPPLEMENT to Web-App S <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM 1 r <br /> �- Yra )rl.r --a : !�r - 5d �r n Zoning Status; CUP; <br /> OWNER AD R (Number, reef,Cit State,Zip) /� A Deed Restriction; CSM <br /> ‘1:7-----? (W�C� 4� (/ �_,A _ X75— Variance(# ) <br /> H ME PHONE CELL PHONE E-MA ADD TS i <br /> lot —j fir, b i . Ar 39,j► 9. a , fil 1 s I ,,/ij ; , ( ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR PA NFORMATP4 N and includes dimensions <br /> AG T NAME �� CONTRACTOR NA <br /> (/ ■--Gid Ir SL111 stfoj n Site Plan including location <br /> At ENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> L 229- d(Ate4 <br /> El(City, te,Zip) (City,State,Zip) Setbacks <br /> 6 1•J 535— <br /> PHONE PHONE ❑ Site Plan approval from <br /> 4 6g 31 P 77 ‘ ` a gg 3 53 -/e1 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS Floor plans to scale <br /> r <br /> PRo;cRTY/LOCATI/_J;+1 INFORMATION. (http://accessdane.co.dane.wi.us/) <br /> PARENT PAR L a BER. CURRENTZONI ACREAGE: n Elevation of property <br /> ❑ <br /> PARCEL frontage drawn to scale. <br /> NUMBER OY- 05-0%--6(1.---80)--6 5 <br /> TOWNSHIP SECTION: <br /> /4: ,/4,/4: ❑ Driveway permits <br /> (state, county. town) <br /> ADDRESS: <br /> c,_,_ e g� n Sanitary permits <br /> CSM' LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 12, ')( / ' / L_:;P. it_.;l_..\. ❑ Zoning District <br /> . This project is/a new building or structure. ❑ Permitted Use? <br /> riThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> DEWER [EPTIC - (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I(f ��-,, ❑ Wetland/Floodplain/ <br /> --- Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: -� 1ST FLOOR/ ❑ ErosionControl permit <br /> 1 TOTAL SQUARE FOOTAGE: j (slopes, disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: G y <br /> (t_,J/') ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -I. -+ ♦ -0., 0 and available options. <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? nYes No (—Don't know <br /> 2. Is there a wetland or floodplain on or near the property? nYes INNNo Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? .... nYes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Wes 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) EYes (at o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 171No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />