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.1). 71 , 7 5 <br /> SUPPLEMENT to Web-App It <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> PL, I),p ll' ker ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) (la Deed Restriction; CSM <br /> CG(1 C/ec /a5 4\ . Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> I -74- Z-0-7/5.6 'tak(t t •Oakel; 61-& o14-4 t I.6d wt (4 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION 1`t'and includes dimensions <br /> AGENT NAME CONT TO',AME <br /> IV / ❑Site Plan including location <br /> AGENT ADDRESS CONTRA, OR ADDRESS of well/septic <br /> (City,State.Zip) (City.State,Zip) ❑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://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING ACREAGE: ❑ Elevation of property <br /> ❑PARCEL _Z��� • 2� frontage drawn to scale. <br /> NUMBER _ <br /> TOWNSHIP: SECTION: <br /> d oh '/4: '/4'/4: — ❑Driveway permits <br /> ADDRESS: <br /> re� (state,county,town) <br /> 9 01 Gle PI WC^y e ❑Sanitary permits <br /> CSM: LOT - SUBDIVISION BLOCK/LOT <br /> '3I'f -7 i (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> e 13(&e e Or c_k <br /> !fi - ❑ Zoning District <br /> . ['This project is a new building or structure. ❑ Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1 ST FLOOR: r.--1 ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> �-� filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 29 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available options, <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 MNo ❑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? Des ❑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) Elves EINo ❑Don't know <br /> 7. Is this to correct a violation? [Yes -gNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) • ■ -+ <br /> 545-112(4/08) <br />