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SUPPLEMENT to Web-App #
<br /> ZONING PERMIT APPLICATION www.countyofdane.com pp
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Si//41 • 48i3X , ,9r4 /i•,7 7.°1/ ❑Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street, i State,Zip) Deed Restriction; CSM
<br /> (D O C 8)2 c /./o o d ')-AIL ,47 yb/zs.-.,Q t..') _<-7,75-7 L Variance(# )
<br /> HOME PHONE CELL PHONE E-MAILADI'RESS
<br /> *o$_ - o a 6 0il-.&S-0-77 0 - ,.`, ., - o.. - - . - 'G.I.Co4.+1 Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRAC OR NAME
<br /> (4' ,Y 1v1 ,4;/21,� 421416-7-WC Quq, cry Niu — o.csr•7" 111 Site Plan including location
<br /> AGENT ADDRESS CONTRAC OR ADDRESS of well/septic
<br /> P a gDx /z /7 D. ,C pc /z
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> Mr_ /1672,E43 t,✓, .S- s ate& I tli ,5-"35 7 z
<br /> PHONE PHONE ❑Site Plan approval from
<br /> to 0%- 9 $ _ 37 7 jr e p c$ 7 9 g _ 3 7 7 y applicable township.
<br /> E-MAIL ADDRESS E-MAIL AD ill RESS
<br /> r�ai/ c°M ❑ Floor plans to scale
<br /> uc f i ti'west ', ,..1---s- u ' / . a M .,44., •. we
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT!ONING: ACREAGE:
<br /> ❑PARCEL D 7a(0_ ,,yV�� 7,s-00 - 7, Ce 7 frontage drawn to scale.
<br /> NUMBER /1v' GI /
<br /> TOWNSHIP: SECTION:
<br /> vria in D N /y .1/4: 5 w '/4'/4: ❑ Driveway permits
<br /> ADDRESS: (state, county, town)
<br /> 11C9 i6 /Y/0 c go 094 adi-1 S c 7ii W/ ❑Sanitary permits
<br /> CSM: LOT SUBDIVISION BL6CK/LOT (public, private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> S/N&L E- fAiii )1/ NAB i ❑ Zoning District
<br /> .
<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 /> r)EWER 17. EPTIC 13-Z p 6 - 0 0 oZ3 (new/e4i0 rig)'
<br /> HEIGHT IN FEET: NUMBER F STORIES: (Not including basement)
<br /> 3a ❑ Wetland/Floodplaln/,
<br /> AREA TO NEAREST SQUA E FOOT ShOreland (attachment)
<br /> (Outside dimensions including unfinished area, attached gar ges and above grade decks or porches)
<br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit ,
<br /> 3 o z �- 4 • OS- ,�, TOTAL SQUARE FOOTAGE: 1 (slopes,�disturbance,;
<br /> 2ND FLOOR: / 3RD FLOOR: f111Jngfaccess�
<br /> /! 6 09 /), l ?fO ❑ Review Location Survey.
<br /> ESTIMATED CONSTRUCTION COST: ♦ --► -•► ♦ { --► $ n cis Q o c, 0, 00 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? Elves No ❑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? Elves 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) ❑Yes No ❑Don't know
<br /> 7. Is this to correct a violation? Elves ®No
<br /> 7i f%5--f3 APPLICATION MUST BE SIGNED
<br /> M (Continue on Back) -0 -0 -0
<br /> 545-112(4/08) / o [ i(/
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