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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 /> Je i t lbrd!i ail ,TvI .Gf/C6 1 1 ' <br /> . Zoging Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State.Zip) <br /> 7631 T e( .-(1- Dt is Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS / <br /> boy-LS$- 3SYO 'rw�∎Ib ra 6' • wA�I. Cow► Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAM <br /> 5CW .Se( R' to Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f welVseptic <br /> (City,State,Zip) (City,State,Zip) E Setbacks <br /> PHONE PHONE ❑Site Plan.approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS �� <br /> [:Ef Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.whusn Elevation of property <br /> PARENT PARCEL NUMBER: CURRE ZONI G: ACREAGE: P P y <br /> ❑ <br /> NUMBER BER U?0S-Lo3-224 S O 2 frontage drawn)ca'scale. <br /> YZ/oyy Ft , <br /> TOWNSHIP: SEC 1 1 r <br /> 7i)tell of/614,441:01 %. c5 Y4%: � IN ❑Drivewa ermits <br /> ADDRESS: (stat ounty,yin) <br /> ?6 3 y 7 er 4,4 C/, de/arm cv t 535-1-3 <br /> �� <br /> CSM: LOT 6c_ SUBDIVISION BLOCK/LOT ❑Sanitary p mlts <br /> f f�acc *Ravi <br /> (public rivate) <br /> PROPOSED PROJECT INFORMATION �TAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6at«0-I .pore!•. ^ &Add St. e?x.S}, de* uS al Ser<en.� /ot)ri+ , &' • ping District <br /> . ['This project is a new building or structure. / � 1� /� ❑erm�ed Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural SS <br /> EWER PEPTIC N J' (new/ xisting) <br /> HEIGHT IN FEET: Si PEPTIC <br /> " NUMBER OF STORIES: (Not includi g basement) <br /> S O / ❑ Wetlan plain/ <br /> Shore! d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionCont�Al permit <br /> __ 2.20 fr L 4, TOTAL SQUARE FOOTAGE: + (slopes,d' urbance, <br /> 2ND FLOOR: 3RD FLOOR: Z filling/a ss) <br /> 22v r/ 1 <br /> ❑ Review Location Surve <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ /U U O O/ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes ErNo ['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? [ 'es ❑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) Eyes �I o ['Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112 taros C--) (Continue on Back) -► -0 -0 <br />