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• SUPPLEMENT to We •APP# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ��� <br /> V .e 'At et ii i� o Lk •C • <br /> Zoning Status;CUP; <br /> W <br /> ONERADD SS (Number, eel,City,We,Z ) - Deed Restriction;GSM <br /> t 01 . + r 1,0 0 .1 ° • rYir: iA ij tiL c. -7G Variance(# ) <br /> HqM O CELL PHONE E-MAIL ADDRESS <br /> ESS <br /> CSR ' "510 'Q Site Plan drawn to scale <br /> AGENT INFORMATION. !CONTRACTOR INFORMATION and/includes dimensions <br /> AGENT NAME CONTRACTOR NAME N/ . <br /> 5 i' 6 A ii•.I./e 'Site Plan including location . <br /> AGENT DDRESS CONTRACTOR ADDRESS of wellseptic <br /> • <br /> (City.State,zip) (City,State,zip) �t 1�1 Setbacks <br /> PHONE PHONE ❑ Site Plan approval/from <br /> . applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> " Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:f;accessdane.co.dane.vvi.us!) 9 Elevation of property <br /> PARENT PARCEL UMBER: CURRENT N1NG: ACREAGE: <br /> PARCEL (^p (r 3'', / Q ( frontage drawn to scale. <br /> NUMBER ���\ w �L I ( � 1 <br /> TOWNSHIP: S£CTjIr ---\ i� ❑.Driveway permits yitAlj; <br /> i+ �cld 1ky — (state,county,town) <br /> ADDRESS: • <br /> • g c, CL _. 0. • L O. & ` c Sanitary permits <br /> csM: LOT SUBDMSION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: ' N • <br /> . ®fihis project is a new building or structure. `. <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: __PERMIT NllM �f — �a — <br /> i�' SEINER ❑SEPTIC <br /> HEIGHT IN FEET. 3 D , NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: <br /> •----.. (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> = SEMENT: 1ST FLOOR: <br /> / Iii 1 _2 �'r lam; TOTAL SQUARE FOOTAGE: l <br /> Fr:FLOOR: • 3RD FLOOR: 4 4i i <br /> 1 ,ESTIMATED ONSTRUcT1ON COST ()0 <br /> (Please roun�to-neerr st dollar) $ 5(0/ 1 - - <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑.Yes I.y No .0 Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes L "No 0 Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑No <br /> 4. Has there been a zoning permit issued for this property In the past 5 years? 2Yes ❑No <br /> 5. Is this project associated•with a rezone/CUP/variance(petition/appeal# ) (l ere blank if none) <br /> 5. Is a location survey required? (see reverse) Yes ❑No 0 Don't know <br /> 7. Is this to correct a violation? ❑Yes VNo <br /> 7 APPLICATION MUST BE SIGNED <br /> 11. il I S , 1 ` j (Continue on Back) + ' .9 <br />