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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> !EAMEQ , -I ' )� el )cam. lam" �e r ' � Zoning Status;CUP; <br /> OWNER A DRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 'P. ...nce(#.3 tc,c - ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan dr. n to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes di ensions <br /> AGENT NAME p CONTRACTOR NAME I ar■ LA'S 0, ❑ Site Plan inc .ding location <br /> AGENT ADD ESS J, r ) CONTRACTOR ADD-.SS of welUseptic <br /> JB'v Vs) 0.'12✓ Ur) <br /> (City,State,Zip) (City,State,Zip) ❑ ■etbacks <br /> if .9 6 04).--, 4-k <br /> PHONE PHONE ❑ Sit- Ian approval from <br /> Co .4;.‘ 'f CS 3 S3 7 13 applic.. e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> LLain'c� P-0,4),sov,, P7,..,�,- <br /> ❑ Floor plans to cale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elev- ion of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> 1:1 NUMCEL � <br /> PAR ` frontag- •raven to scale. <br /> BER CY CIS CID.G N I C,1-7/ <br /> TOWNSHIP: \ SECTION: <br /> C\ /�o•� r 1/4: 1/41/4: ❑ Driveway per ,its <br /> ADDR $S �� L (state,county,t. n) <br /> I oM�l Q Or ❑ Sanitary permits <br /> CSM` LOT r SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> 4 <br /> P OJE T DESCRIPTl J s <br /> IC eel e (2 v1�'QPI-0, ,2/n /13 L • Dist <br /> . ❑This project is a new building or structure. 0 p'_ Use? <br /> VThis project is an addition/alteration to an existing building or structure. <br /> ANITARY SERVICE: PERMIT/NBE Riff., °a "' <br /> SEWER SEPTIC �" ( ' iy " ®) <br /> HEIGHT I ET: NUMBER OF TORIES: (Not including basement) <br /> 13 0 i Wetland .� � <br /> AREA TO NEAREST SQUARE FOOT: ) �� <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: 3'.-+i , '' r rpsion : g d a e,,„ <br /> 2ND FLOOR: 3RD FLOOR: a�n ; <br /> 0 R: a V.-:tiOn Survey <br /> EST ATED CONSTRUCTION COS : ar3C £ . 1S,. <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? ❑Yes ❑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? ❑Yes ❑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? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ —► <br /> 545-112(4/08) <br />