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4-34‘ 45 <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ° NAME <br /> V 2 e-.t`CtI an <br /> ftov , (...1.- C- 0 Zoning Status;CUP; <br /> OWNER DO IS(Number- cii II Deed Restriction;CSM <br /> 1 tJ 01 i 410 IJ-( b / lit ,f ta, 1/ 5y -1, Variance(# ) <br /> HgMft O -3r0 CELL PHONE E-MMLADDRESS <br /> CC 'Ct 0 Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME . CONTRACTOR NAME <br /> 5 u AS ye 0 Site Plan including location . <br /> AGENT w ESS ft-ft CONTRACTOR ADDRESS ofwell/septic <br /> (City.Mote,Zip) (Oha Smbl.ZIP) 0 Setbacks <br /> PHONE • PHONE • ' 0 Site Plan approval from <br /> applicable township. <br /> E-MAILADORESS E-MAILADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:!accessdane.ce.dane.wi.usf) [] Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE:PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP:�/y� SECTION 0 DrlveWaypermits <br /> I\% A...\.4. 611 _ ��a: ����i:,� (state,county,town) <br /> ADDRESS: , <br /> p,�Q.!�., � .lei.► Ol ❑S$nitarypermlts <br /> cur: ice: LOT r SUBDIVISION BLOCKAAT (public,private) <br /> 1'OU-1.10110 <br /> PROPOSED PROJECT INFORMATION 5 PROJEOTDESCRIPTION: <br /> p, QA(! 0 nSi`t^Lac h0 1 <br /> s project is a new building or structure. <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> • <br /> -- sANITARVIERYICE: P _ r'1 t ,r 00 1 �� -- • _ <br /> 0 SEWER Q SEPTIC t 3 CT <br /> F�It3M,INPrtl: 30 , • -NUMBEROP-STORIES(Notiner-bewm.n!) <br /> TO NEAREST SQUARE FOOT. <br /> (Outside dimensions Including area,attached garages end above grade decks or porches) <br /> BASEMENT. c' IST FLOOR <br /> /3 l 7 1:251 arOTAL SQUARE FOOTAGE: ,. <br /> AND BOOR: i <br /> =FLOOR: <br /> 1 <br /> ESTIMATED CONSTRUCTION COST. -. ., -► ♦ -► -. $ 45 (� '�3 DO <br /> (Meese round to nearest dollar) I ,,// <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 0.Yes L1�.No .0 Don't know <br /> 2. Is there a wetland or lloodplain on or near the property? 0 Yes 040 0 Don't know <br /> 3..Have you talked with the township about your project and are they in agreement? L,�ybs 0 No <br /> 4. Has Wes there been a zoning permit issued for this property in the past 5 years? es 0 No <br /> 5. Is this project assocated•wtth a rezons/CUPNariance(petition/appeal# ) pare blank if none) <br /> 6. Is a location survey required? (see reverse) Yes 0 No 0 Don't know <br /> 7. Is this to correct a violation? 0Yes (V'No <br /> APPLICATION MUST BE SIGNED <br /> • (Continue on Beck) -► <br /> 545.111 NM <br /> I <br /> 1 <br /> I <br />