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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> o N a� 64�J�`e_ Cy rt ( e47\._ ❑Zoning Status; CUP; <br /> OWNER ADDRESS Number,S'reet,City,State,Zip1,1 f)\ J 1�`+,n�C �7 Deed Restriction; CSI/) <br /> �l4- t�` /lV t f�l� �C . � C ( / Variance(# ) <br /> HOME PHONE CELL PHONE 'E-MAIL AILA DRESS <br /> 40K-V35--3193 (oOg-Al. - k3 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I 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-MAIL ADDRESS 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 ZON NG: �/ ACREAGE: <br /> ❑ <br /> NUMBER <br /> PARCEL <br /> Db/0 -/ l i-gs>O/ A ../( . 8 14 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> •14 kAkit IA: '/4'/4: ❑ Driveway permits <br /> AD..��DR��ES'S:II ,�j,�� f�,�} (state, county,town) <br /> G \ 4 I SO"�r�i\2'x^3 ' ' Q+f� I W t -S3 1S ❑Sanitary permits <br /> CSM: LOT SUB ISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D <br /> \., <br /> 1/4 ❑ Zoning District <br /> . <br /> This 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 /> FEWER lytEPTIC (new/existing) <br /> HEIGHT IN FEET / NUMBER OF STORIES: (Not including basement) <br /> i/ I L:1 Wetland/Floodplain/ <br /> [ Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: / ❑ ErosionControl permit <br /> ,+ta"r i I 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: L� , <br /> filling/access) <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ' I ('�(� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ 14/w� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IZNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes n o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes INo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes igiNo <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 o ❑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) <br />