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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 /> > Tie AM S ET-7— ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,Stat Zip) Deed Restriction; CSM <br /> c S-cc 0 /1-K 14142r_ IL Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> bads 72-S-2- ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 0 O (2-'4/ 3 .-et 3�- Z A (—� ` 9 frontage drawn to scale. <br /> AGre-5 <br /> TOWNSHIP: SECTION: <br /> A Ely NA- 1/4: '/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county, town) <br /> SS SS 0ictK P1 2e " <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . EThis project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> DEVVER ✓ EPTIC new/existing) <br /> HEIGHT IN FEET. / NUMBER OF STORIES: (Not including basement) <br /> // / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore1and (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) =! <br /> BASEMENT: 1ST FLOOR: ❑ E"oslOnContlol permit'• <br /> 3 r c SQ 1 TOTAL SQUARE FOOTAGE: 4, (slopes disturbance, <br /> 2ND FLOOR: 3RD FLOOR: U-/CQ filling/access) <br /> 3 [c <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �0©� and available options. <br /> ♦ <br /> (Please round to nearest dollar) —0 ♦ —0 —0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Peso ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies Bl0 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [EYes ❑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 ElKo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes [ lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —0 —0 -♦ <br /> 545-112(4/08) <br />