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t4) 5q-0 SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWAJER NAME / <br /> �/"7,"f jen oc 8L/i /(plr/"/1 n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ( . ° /0 c- ZA l07,1 l`S feel Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> J7 -SD `d o - n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> i('19✓1 Lirpfs�G i1 C- /e/ ti y n Site Plan including location <br /> AGENT ADDRESS CAI TRACTOR ADDRESS of well/septic <br /> noes r7 LG ;. 74is /2/ r.o, .30_ c. ,2 <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> SToL`�Ll%t� -z,`.- 3-i ' v8 TA 4....51, pt..1 3,5�13 <br /> PH ONE PHONE ❑ Site Plan approval from <br /> 7..-e) S/� D C 5 Sao -_?-9 3-S'..cs-a applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL / / // frontage drawn to scale. <br /> NUMBER LS/^'7 G l ,lO <br /> TOWNSHIP: SECTION: <br /> �Iin,� y '/4: '/a'/a: El Driveway permits <br /> ADDRESS: r A ,� (state, county,town) <br /> aU6Pic. Co /4 i.Sic`C ❑ Sanitary permits <br /> CSM: LO? SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> f.3‘i ," di'''' ❑ Zoning District <br /> . This 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 /> EWER FIEPTIC (new/existing) <br /> HEIGHT IN FEET: 1 MBER OF STORIES: (Not including basement) <br /> f2 X ram s `� j / CI Wetland/Floodplain/ <br /> • ( <br /> ST S Shoreland (attachment) <br /> AREA T SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ll <br /> BASEMENT 1ST FLOOR:124:o <br /> Erosion Co t I permit <br /> �o 1 TOTAL SQUARE FOOTAGE: 1 (Sl I rb�i . <br /> fillin /aces <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1 9'63 <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ -+ -0. ♦ ..02f�, Qpd , ea <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑No fDon't know <br /> 2. Is there a wetland or floodplain on or near the property? es ❑No nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Jr ON <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes 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) nYeslo [Don't know <br /> 7. Is this to correct a violation? ,)(es ❑No <br /> � lv <br /> e�GLC/f (--44 4t1 APPLICATION MUST BE SIGNED <br /> (Continue on Back) - - -0 <br /> 545-112(4/08) <br /> 1/0 /t\A c - - C' -- . <br />