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7'3 <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> L/ s 4Y5 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> r3 Z h F& nP /4(464/4,/E-,W( .S)f ° Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> O '-7fr:L ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 2 'r y�t�Y ��r1,iJ /�✓ ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) GI Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS <br /> E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 6' Wo96 -.1 f�t'48/O- I '/C ?() , 29 7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Rkileg :, 17f 1/a: 141/a: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: STAFF REV!EW <br /> ❑,'Zoning'District <br /> CI This project is a new building or structure. ❑ Permitted Use <br /> aThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> ❑SEWER 4 SEPTIC ( " <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> / ❑`WetfalRI ft3,pt�ain/ ,t- <br /> AREA TO NEAREST SQUARE FOOT: h+artatten). <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: „1„,:::., <br /> /T- TOTAL SQUARE FOOTAGE: o�,” P L' I-� b �''- <br /> l <br /> 2ND FLOOR: 3RD FLOOR: ' <br /> et0 SF ESTIMATED CONSTRUCTION COST: ❑ tievlewloca t irY �/ <br /> (Please round to nearest dollar) "� '� l�j�0 and available ons.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ®No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? <br /> 11 Yes la No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? taYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑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) ❑Yes Ei No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,5 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ -+ <br /> 545-112(4/08) <br />