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S(04, 05 <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER MME <br /> Cti(I-`-t D A-(L) Z` ❑ Zoning Status;CUP; <br /> -OWNER ADDRESS(Numbberr Street,City,State,A) , ° Deed Restriction;CSM V- <br /> 95-)5 fin Kull e fir Q Y-LD�qn!Q , —. D Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ((Dcd"�tb I—133' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 'CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 6-a 1) �v Z l}'LW ❑ Site Plan including location . <br /> AGENT ADORES '}( C l,- // CONTRACTOR ADDRAS of well/septic <br /> 9 515 f0"`' n3 i�c f i/ <br /> (My,State,Zip) J (City,state,zip) ❑ Setbacks t/' <br /> ina 1 6 m(Mkt WI 33560 • <br /> PHONE PHONE ❑ Plan approval from <br /> 19 5 -- 3,0c,— /3'3 � applicable township: <br /> E-MAIL ADDRESS E-mm_ADDRESS <br /> 6-p., a ee_ii tan 6eS, ;'Yh <br /> 0 plans to scale <br /> ,11 <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL �. A_ , N frontage drawn to scale. <br /> NUMBER 0AJi1 NM k A <br /> TOWNSHIP: - SECTION: ❑ Driveway permits l O en '/.: 1/414: (State,county,town) A 10 - cl <br /> AODRE S: I <br /> �� S D r1 it 1 Va� ❑ Sanitary permits ,,,,,' <br /> CSM: LOT SUBDIVISI /t BLOCKAAT (public,private) <br /> •r //.t,, <br /> PROPOSED PROJECT INFORMATION t i r , <br /> PROJECT DESCRIPTION: S Fl - g t Q„ l Cg)' <br /> uC 11-t n )+r ' ri <br /> . CThis project Is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT 6oN'��UMBER: CO <br /> SEWER ❑SEPTIC 18 Orel i — (J /3 <br /> HE G ,FEES i ? ,, , C_; NUMBER OF STORIES: (Not Including basement) <br /> AREA 70 NEAREST SQUARE FOOT , <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) y?; '.,;: =1 <br /> EMENT: /Mr--. 1ST FLOOR: � �j ��4 <br /> 33 I • -__ a 'p 1031 j TOTA • OTAGE: j . <br /> 'Jd s <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3 '� <br /> ESTIMATED CONSTRUCTION COST: vs .. <br /> -♦ --0 ♦ -► -i , <br /> (Please round to nearest dollar) '♦ a r��0 ;�`,:z z';'r `_,_� ._:.:-:1? <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ........... U Yes o ❑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 0,�,/No JJ <br /> 4. Has there been a zoning permit Issued for this property In the past 5 years? ❑Yes U?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) dYes ❑)lo ❑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 />