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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 /> To M o- 1-.se,. Loup oning Status; CUP; <br /> OWNER ADDRESS (Number,Stree,city,State,Zip) Deed Restriction; CSM <br /> \V/ (2�9 odsvcecv ejrc-(e Rwi 1ow.d lam! 5-3 5$4 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRtSS <br /> bat S45 9&S1 ( •u., f • rna•I . Co.M Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> gO-4 t,kco' iSLC.kI!!f /40 wt, son pro'rt,.,.-t.,• ite Plan including location <br /> AGENT ADDRESS - CONTRACTOR ADDRESS of well/septic <br /> id ir norm. {.w+t - 20t /Ma/s a. Let K e <br /> (City,State,Zip) (City,/ State,Zip) tbacks <br /> (City, <br /> L Gro ,e W( 54527 `O C ( roe Cu)( S3S27 <br /> PHONE " PHONE ❑Site P royal from <br /> (Doi 2(2 — 3 i 3q we V233 /' applicabl o ship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> N.,44 IQ bttkt,-AoAC.:At•(datM+lAtamo t F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) atlon of property <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: <br /> ❑PARCEL 06-21 65./0 w I'Z—IID'1S_9 /4"' cEA) l ZS rontage drawn to scale. <br /> NUMBER 1•Q'; �� <br /> TOWNSHIP: SECTION: <br /> R�,t-le.,...d (rs tv fZiO f) i( .1/4: Nk' '/4'/4: A - ❑ Drive ermits <br /> ✓DDRESS: (St c nty, town) <br /> 12$9 000ee50,ew Gor C.k [ anitary permits -'cc j <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> S SunRtSe il. a (public, . - - -s-o�� <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: STAFF REVIEW <br /> Bd Hoorn ace ,�•un ' OuC f tx. sf..� a�e�J e . ttsno Ee °°". ning District if, <br /> . ❑This project is a new building or structure. <br /> P fitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT U BER: ❑ Rural Address <br /> W <br /> EER EPTIC � I v —/ 7) (n- • <br /> HEIGH FEET: i 1 NUMBER OF STORIES: (Not including basement) <br /> _ <br /> AREA TO NEAREST SQUARE FOOT: ❑ et- •••plain/ <br /> V� '- Sh• -- - Ad (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ Erosi..Control permit <br /> ��� j TOTAL SQUARE FOOTAGE: j (slopes, •' turbance, <br /> Min., -A- s) <br /> 2ND FLOOR: 3RD FLOOR: �\ <br /> V\ ❑ Review •-<tion Survey <br /> ESTIMA D CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ p and - -ila• - options. <br /> (Please round to nearest dollar) $ 0 er)0. OU <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? aes !Rio Don'tknoPv <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 RiNo <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 EiNo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes Ro <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />