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2. ` o ca SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION Www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 121/k 5.-, CLISSA Mlffk\, C(.) A(LT ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 4'4 E�i K � ( ECG art , \� S-35-1-5 Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILA�DRESS <br /> 59(,- Zl ' ,rp,rk-,.,Ac't-d. .,.,"14ik- ' ❑ Site VlaD,drawn to scale <br /> AGENT INFORMATION CONTIRACTOR INFORMATION and iV6udes d• ensions <br /> AGENT NAME CONT'' TOR NAME <br /> A1. L_ ` 4 Gto- C3SThrk A 0 to CS ❑ Site PI • eluding location <br /> AGENT ADDRESS CO O TR/8cTOR ADDRESS of well/septic <br /> 221D RstAST ?•b• 1 a�n 1 k <br /> (City,State,Zip) (City,State,Zip) ❑ Set CkS <br /> DREE�or-t , W r 53 5-4-5 QZE•;c,ort. , Y-7‘... S 3 S-i-S <br /> PHONE PHONE El Site Plan p al from <br /> -2A"L- -L-7_11> E applicab Ip. <br /> E-MAIL ADDRESS E-MAILA Z9:-% <br /> ESS <br /> 4St 6atr cis �F1��,Ei w4► .�•M AC ❑ Floor to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation f perty <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: <br /> L is❑ NUMBER O 2 � O(01 O ' L' 1.' rn o.0 �N -4 S3 .1s,c1 frontage n to scale. <br /> TOWNSHIP: SECTION: <br /> Z 1/4: 1/4'/a: ❑ Driv ay mits <br /> Apt 1 �' Ni�`i (stat nty,town) <br /> PR 1>Jc_sS CT' ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 5 3 (public,pr} ) r low <br /> PROJECT DESCRIPTION: -V't.CA 1`41 `i r <br /> folic(/' � yr <br /> NEW SINt,LE ��1 L'-f - E:...,�9t:h1�� fCj^ � , <br /> r �. '.. <br /> . OThis project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> �/ ". -f SANITARY SERVICE: PERMIT UMBER: i ' r <br /> t p 1 vtg nSEWER SEPTIC \3 '' c I S " 00 19-1— <br /> EIGHT IINN FFEET: 1 NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, atta hedi 'rages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 4r <br /> TOTAL SQUARE FOOTAGE: 1 (slopes,d , 'l <br /> 2ND FLOOR: 3RD FLOOR: W/GA AMC <br /> 1 j ,r/ _ 7,7i-tit 4 ' D� <br /> yd1 -� ` "/ LI Raw Locatipn,Surer <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ and available�o .`, <br /> (Please round to nearest dollar) y5, O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes NINo ❑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 �No <br /> 5. Is this project associated with a rezone/CUP/variatce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) 1 ❑Yes ®No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0 -♦ <br /> 545-112(4/08) <br />