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St e Nth v.,..) <br /> r <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME '/ / <br /> Alan L. Se6rtjjek and Kfltt�pel)y P $o6raHe.K . ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) / Deed Restriction; CSM <br /> 28'1 i V;n 6uc , a ) S A 14 42JItn�I cvr sZ. O variance(# ) <br /> HOME PHONE CELL PHONE C4142 K) E-MAIL ADDRESS <br /> 4,08-g3 7-2444 668-514-o770 a(an,sdont ttlee hank 4an,'0,We c,Iwt ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> by a tie(' ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> SRNfrni. cvte-. <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> (ooh'-51 6 O/?0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> et fa 14,Se&-aftrr°' ,, '�1Z°r�Fn ❑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 /> ❑PARCEL j �� T /� frontage drawn to scale. <br /> NUMBER /1 t:q�^ /'�`C� F1 � 7�� g <br /> TOWNSHIP: SEC 10 : A 1 <br /> Zri SfoL 1/4: N tssA) '/%: 1 v ❑ Driveway permits <br /> ADDRESS: p <br /> (state,county,town) <br /> Z r'Z 1 'Vr`(1 bd i I e{I14 SS.S <br /> �' / �t ''t 1 WS 90 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> CM i c 1 (public,private) <br /> PROPOSED PROJECT INFORMATION ' STAFF`REVIEW.. .. <br /> / <br /> PROJECT DESCRIPTION: <br /> S if' 7� V <br /> New he� � � � Li Zonlrig District <br /> . ®`This project is a new building or structure. .0 'permitted Use? <br /> ❑This project is an addition/ teration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Z Rural Address <br /> EWER EPTIC �/ . _ (neW/existing) <br /> HEIGHT IN t,=- ' ' ` ' NUMBER OF STORIES: (Not including basement) <br /> a—/`1 o eke L] V11etiand/Fioodpiain/ , <br /> 4,, . Shoreland (attachment) <br /> -, ,. '' -,A(t A1O NEAREST SQUARE FOOT: <br /> (Outside imensions including unfinished area,attached garages and above grade decks or porches) is <br /> BASEMENT: 1ST FLOOR: `Ioricantrol permit <br /> • 4,z..' c 4.0 + TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> x f ling!access <br /> 2ND FLOOR: 3RD FLOOR: •€ 4 <br /> Review-Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦♦ ♦ ♦ Qp and available options.(Please round to nearest dollar) ��Oct), <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EINo ❑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? I Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eyes EN <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 INNo ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) ^//(0 ` <br /> 1 <br />