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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 /> KQt\ ..1•• ArT, epQ ^f- ❑Zoning Status; CUP; <br /> OWNER ADDRESS (NumberStreet,C'ty,State,Zip) Deed Restriction; CSM <br /> GAS' \wk)J1� lnlap. e,. a7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL` ADDRESS i ,1 0 V <br /> (CUB 42-lei-12CO 1�eV i i 1 , OC )191c r� ba,Vec i I'Y Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ` �.� <br /> "' <br /> ��'Q:r�=��� -v'f OT$0.16 ❑Site Plan including location <br /> AGENT ADDRESS -1CyO��`NTRACTOR ADDRESS of well/sep tic <br /> Ivc /ioP0 - <br /> (City.State,Zip) (City,State,Zip) ❑Setbacks <br /> Jnca.. 5 .. .. �� <br /> PHONE PHONE ❑Site Plan approval from <br /> - -70 j 64-330--S-13t applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS �� �� .Cow ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PA�RC,L NUMBER: !� CURRENT;WING: ACREAGE: <br /> ❑NUMBER Or^? �1 Iii 1 A N-1. 2'i.� frontage drawn to scale. <br /> TOWNSHIP:, .. `` SECTION: <br /> Srr `Q,Al 1/4: '/4'/4: ❑Driveway permits <br /> ADDRE5�6J� (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: p . 1 <br /> 001(4 S'-cAro. ("X7'...Pt-,,,,,"2, -1�v,1c;t L ❑ Zoning District <br /> . EThis project is a new building or structure. • ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> HEWER [)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> a 2 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> . ,a-ID-- 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> `�a� LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ Q t �,'� •1 and available options. <br /> (Please round to nearest dollar) $�j.J�V <br /> 1. The property is within 300 feet of a stream or 1000 feet from pond�r lake? ['Yes J�C to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? i <br /> Yes ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 'lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Rio <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 o ['Don't know <br /> 7. Is this to correct a violation? [Yes gi o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) - -+ -0 <br /> 545-112(4/08) <br />