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i • TD <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME // <br /> 71 1'v16A✓1 : -� S� !A A 4 (( �vi.,-. Se -■ ?/ <br /> ❑Zoning Status UP; Ge �(g <br /> OWNER ADDRESS (Number,Street,City,State,Zip) n Deed Re • ion;CSM <br /> c 1 c 14 la( `t IA 0 /\k Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> -76---‘)7 t l3i't , l■ m-■-\ r• . 0,COQ❑Site Plan ra to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includ dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 0 r c (.o /PIO 0 v--j4 r(Cc ■S40Q 4 c4t`13•\ ❑Site PIa i luding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/s tic <br /> /3 tai 63 �- -3 ;-3 <br /> (City,State,Zip) (City,Stat Zip ❑Sei ks <br /> L-0 .0 L . ,‘ .. 53 1-5C- ��-',✓� <br /> PHONE PHONE ❑Site Pla' a t •t om <br /> 0 5,- a / d•-/, r 9' applic-),l_ + ip. <br /> E-MAIL ADDRESS ,, i E-MAIL ADDRESS <br /> Po AI �A t^ 6 c�( @ i+fu+t . Co-, ❑ Floor plans o ale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of prop <br /> frontage dra n scale. <br /> ID NUMBER PARCEL b ¢FO o -0 -6062-o <br /> TOWNSHIP: SECTION: <br /> c le — c,cQ i 10 1/4: 1 41/a: ❑Drivew per its <br /> ADDRESS: (state,c town) <br /> 7 4.o I ono V ❑Sanitary permits <br /> ermits <br /> CSM: LOT SUBDIVISI BLOCK/LOT �nn <br /> .n (public,private) • t Y . <br /> PROPOSED PROJECT INFORMATION STAFF O <br /> PROJECT DESCRIPTIOyy.�/ <br /> A ;P c ) ("&-o-,-,e ❑ Zoning D <br /> his project is a new building or structure. ❑ Permitte se? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ R al Address <br /> EWER .EPTIC ) 3— aO t �j •-p0 07 fm►/existing). . <br /> HEIGHT IN FEET: f NUMBER OF STORIES: (Not including basement) <br /> 7 C / ❑ Wetlan• F .•�, -•• <br /> ( Shore ■ (. L.« ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garaged above grade decks or porches) <br /> ❑ Erosipn o of permit <br /> BASEM NT:o 1 ST `` :� U (slo - , •( � •Y nCe,l TOTAL SQUARE FOOTAGE: 4, <br /> filli ; - _- ) <br /> 2ND FLOOR: 300R: <br /> 6 63 ❑ Revi �t'•n Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -0. -0. -0. -0. -0. � and options. <br /> (Please round to nearest dollar) $ S //0 00 1. The property is within 300 feet of a stream or 1000 feet from a pond for lake? [Yes Dlo ®Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes OW 14pon't know <br /> 3. Have you talked with the township about your project and are they in agreement? :Yes [ 10 <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 'lo <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) Ekes 0 o ❑Don't know <br /> 7. Is this to correct a violation? :Yes r o <br /> / APPLICATION MUST BE SIGNED II i <br /> ' .� /..2-D.,7�j (Continue on Back) -►545-112(4108) ( ���lll.....))l <br />