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SUPPLEMENT to INotkAPP# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> CUSTOMER TO PROVIDE <br /> owk L i1/41/416. �1... t <br /> Zoning Status; CUP; <br /> ` Deed Restriction; CSM <br /> OWNER ADDRESS Number,Street,City,State Zi 0 N,} W+ 5 t Variance(# ) <br /> HOME PHONE l CELL PHONE E-MAIL ADD Ss Site Plan drawn to scale <br /> a '> 'L4 4 OatC 1 k . � <br /> CONTRACTOR INFORMATION and includes dimensions <br /> AGENT INFORMATION CONTRACTOR NAME <br /> AGENT NAME 0 Site Plan including location <br /> AGENT ADDRESS <br /> CONTRACTOR ADDRESS of well/septic <br /> ❑ Setbacks <br /> (City,State,Zip) (City,State,Zip) <br /> ❑Site Plan approval from <br /> PHONE PHONE applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/aecsssdane.co.dane.wi.us/ 0 Elevation of property <br /> PARENT PARCEL NUMBER: �(� CUR ENT ZONING. ACRE4G frontage drawn to scale. <br /> ❑NUMBER Deoct-~ D33- ..��.� t l'T(J! <br /> TOWNSHIP: SECTION: Driveway permits 3 Y4: '�"'�4 (state,county,town) <br /> ADDR ss: NArre* t , 3 []Sanitary permits <br /> CSM: I LOT I SUBDIVISION BLOCK/LOT (public, private) <br /> ,PROPOSED_PROJECT INFORMATION ' <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION ��++ r t.1 Zoning District <br /> \. I i•of Groi,,,,o( or-preivu. [/]This project is a new building or structure. <br /> Li Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. 0 Rural Address <br /> SANITARY SERVICE: PERMIT NUMBER: (new/existing) <br /> FIEWER yiEPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement)n t U Wetland/Floodplain/ <br /> ! ' '. Shoreland (attachment) <br /> I" AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT t5T FLOOR: ♦ TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR. 3RD FLOOR: 'Mg: 5G. . FT t � <br /> v ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: .r <br /> CO 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? QYes No ro e rty? QYes o Don't know 0Don't know <br /> p <br /> 2. Is there a wetland or floodplain on or near the property? <br /> Have you talked with the township about your project and are they in agreement? gres flNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Rres ❑No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (le a blank if none)eso ]Don't know <br /> n 6. Is a location survey required? (see reverse) 2TeS nNo <br /> 7. Is this to correct a violation? <br /> 7q5 rvi- 0 cye k_' APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -4. -► <br /> 545-112(4108) 6' / v <br /> ILIA: <br />