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;;SUPPLEMENT to_Web App#; <br /> www.countyofdane.com <br /> •ROPERTY OWNER INFORMATION _....-" ,;..mi- '• _-• ;- -'3 ''E CUSTOMER TO PROVIDE <br /> OWNER N /� y- 1� <br /> /4 sot" ---1- /T h'- . <br /> Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> /0113. c 4 /D 1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> g/3 7 3(7cri 576 Q 3 7 y ..S a( Put 72 / 6 � I 'Site Plan drawn to scale <br /> AGENT'INFORMATIOhI _ . 's , r•:; ,CONTRACTOR`�INFORMATION-. Y= _ , and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS • of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORIII-IATIANY':(http/laacessdane co,dane.vui.us!) _ ❑ Elevation of property <br /> PARENT PAR ELN BER. CURRENT Z ING: ACREAGE: <br /> NUMBER 0( -0q ;�r1) .-' ! jx frontage drawn to scale. <br /> TOWNSHIP: fis 1 110\n10`� . SE ON: (�(.`� ry� Ik <br /> C ' '/a: s...5.% <br /> �- '/4'/a: V�'�' " ❑ Driveway permits <br /> ADDRESS: atn) <br /> C /1\r\) Sanita permits <br /> ❑Sanitary <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT::INFORMATION '; - STAFF:REVIEW£ ` <br /> PROD T DESCRIPTION: =} h q , i <br /> rrc.e s it 411 /• 'ON at A— 6o <br /> a zomng Di�fr�ct� ��.� ��': <br /> -g 4 ei s% <br /> OThis project is a new building or structure. ; s - _ t <br /> O �ermittid.'Use- = <br /> ❑This project is an addition/alteration to an existing building or structure. - z - 4 <br /> SANITARY SERVICE: i PERMIT NUMBER: 1--Vi ar giat�S 3 3 <br /> • r)EWER Nt EPTIC r_a a(�e IS Ird <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) rk +--'.0 ._` <br /> LQ Wetlarld/FlOQdplaln/ '� <br /> r Shpiel i itac fraeptf) - <br /> AREATO NEAREST SQUARE FOOT: :�`_ .�°., �k - <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) `�� <br /> BASEMENT 1 ST FLOOR: [A$]QFd ...991LC pert97- <br /> j TOTAL SQUARE FOOTAGE: + `''IS11iiliatS UTb Ce; f <br /> 2ND FLOOR: 3RD FLOOR: 4i° t 0e, S' e r'f <br /> C � = <br /> are <br /> D e 670tocatttz_n St#ey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ arrd a a�abjeb� t ns, <br /> (Please round to nearest dollar) ��. 000 _ . t 4.L. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o - ❑Don't.know <br /> 2. Is there a wetland or floodplain on or near the property? []Yes 4o _['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ' o_ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan it none) <br /> 6. Is a location survey required? (see reverse) Elves No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -+ <br /> 545-112(4108) <br />