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SUPPLEMENTto Web APps#` <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> •.E TY: .W E- I . 1. , , f ::k 5,-z` , , 31,71 W-••n= CUSTOMER TO PROVIDE <br /> OWNER N:. ( i1 I,. <br /> 04ACt - NCLS°rl Zoning Status; CUP; <br /> OWNER ADDRESS N ber,Street,C' State,Z' <br /> (�m City, Zip) Deed Restriction; CSM <br /> 10 Z 9 CoH,ln41 ,d f Variance(# ) <br /> HOME PHONE CEL PHONE E-MAIL ADDRESS <br /> b0at90'716 Z. • n Site Plan drawn to scale <br /> AGENT'INFORM A_TIONI3,, .� '' y ti A*CONTI Aa-Att NFORIIA%tTIOii _ n { and includes dimensions L <br /> AGENT NAME CONTRACTOR NAME <br /> �p Ne�� n Site Plan including location <br /> AGENT ADDRES CONTRACTOR ADDRESS • of well/septic <br /> (0Z1 Cottr ra..4 <br /> (City,State,Zip) (City,State,Zip) 111 Setbacks <br /> EAcLv \ _ 43<< S-3S-31 <br /> PHONE PHONE ❑Site Plan approval from <br /> C0'82'70,7181- - applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS - <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMAT[OM> (httpa/aecesSdane.co, ne:vin.us/); . :' ❑ Elevation of properly <br /> P NT PARCEL NUMBER: .. CURRENT ACREAGE: frontage drawn to scale. <br /> NUMBER OS./Z'C42• y0�-7 4— 1 CE/0 - 3ZIlch" <br /> TOWNSHIP: - SECTION: <br /> V(6rorN q_S.(2. ,/: �� ,/A: ❑Driveway permits <br /> ADDRESS:, C (state, county, town) <br /> 1021 roa9k ECC Ci.t v. u i . ..�3534 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT-INFORMATION _ <br /> PROJECT DESCRIPTION: c • P tx-� '- <br /> cv,rdbw� - <br /> @, 0,.1 Ili ,,g ; - <br /> • ❑This project is a new building or structure. 1 ed. =� ° <br /> Is project is an addition/alteration to an existing building or structure. a _ _ <br /> f�. - FAti a Te � <br /> SANITARY SERVICE: PERMIT NUMBER: �.� � �, �k <br /> r)EWER riEPTIC "� B--v"-> ,�-'r 4sft <br /> HEIGHT IN FEET: , NUMBER OF STORIES: (Not including basement) ''` E �t ° <br /> . .)Z ` i€ , o/if0.e, fe z <br /> • • <br /> Q a ea °e` ` <br /> AREA TO NEAREST SQUARE FOOT - i � y 'r _" <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) m.�'°----','-i•-•,;--..---." <br /> BASEMENT: 1ST FLOOR: I r� e- <br /> Q6 - 4, TOTAL SQUARE FOOTAGE 4, r ° -it* r <br /> 2ND FLOOR: 3RD FLOOR: • 76 4 rte- ` <br /> . t e -' E a e - .,-y --- <br /> ESTIMATED CONSTRUCTION COST s <br /> e e <br /> ;s <br /> —► - —► —► -o $ 5-6110(Please round to nearest dollar) : -- ,1„-•4 e-im <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? []Yes ' o.•• f 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 • 016 • . <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 a. • ['Don't know <br /> 7. Is this to correct a violation? ❑Yes 12irro _ <br /> • <br /> • <br /> • <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -► -► <br /> 545-192{4roe) - <br />