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.SUPPLEMENT to.Web∎App`# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY.OWNER:INFORMATION _`x - ' OFFICE,U S E ONLY <br /> OWNER NAME <br /> ,� _ Cl Zonin District <br /> e ss I C A .� . /,�/�Q v° c1 g <br /> OWNER ADDRESS (Number;Street,City,State,Zip) 53 C SC? <br /> �j /t,'ca v^ /Y�c4..� Ir 1 C.'' .._; ❑ Permitted Use? " <br /> PHONE E-MAILADDRESS <br /> �O !�3 �1 i I l C �' ' /t j zo g Status; CUP; , <br /> 1„( °r "i'Y 'CONTRACTOR:°1NFORMAT,ION.a ,.3, {'i; ` "'�: . Deed Restriction; CSM <br /> AGENT INFORMATION 1=,�+.-�. � + .� .�� <br /> AGENT NAME CONTRACTOR NAME Variancei(# )• <br /> AGENT ADDRESS CONTRACTOR ADDRESS `.0 Site::Plan"drawn,to,scale <br /> ` .aria"includes dimensions,"- <br /> (City,state,Zip) (City,state,Zip) <br /> 0 Site Plan including location", <br /> PHONE <br /> PHONE of well/septic <br /> E-MAILADDRESS <br /> E-MAILADDRESS Q`Setbacks <br /> PROPERTY/LOCATIGWINF,ORMATION),Ihttpellaecessdane-:**Aainew7 us/)' }.i!�`' ' {` 0 Site Plan approval from <br /> PARENT PARCEL NUMBER: <br /> ZONING: ACREAGE: ,applicable township <br /> D PARCEL <br /> NUMBER SECTION: <br /> TOWNSHIP: Rural Address <br /> 1%. 141%: n S r <br /> .�.� x<(i..6*existing) <br /> r <br /> ADDRES � __ '3 3—&`1 4 l 3 "1-)4)v�;'r.) A7.�<- ION Y Floor plans to scale <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> r Y� 'WYj4. k V <br /> <e igi <br /> iri 1 ` I to 1 • © Elev;ation:of property <br /> ( frontage drawn to scale <br /> PROJECT DESCRIPTION: -s a <br /> x� +Driveway permits <br /> `� (stale, county,town) <br /> U This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure.[],Sa()ttaryxpermit ` <br /> SANITARY SERVICE: , <br /> PERMIT NUMBER: (pibllc,private) <br /> ❑SEWER `bi - PTIC ”' 4 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) Q We=tland/Floodplaln/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Q E roSiondantro b pecrme <br /> i <br /> BASEMENT 1ST FLOOR: /S10peS dsura , <br /> e"- j, TOTAL SQUARE FOOTAGE: 4, f rling/aCo f t <br /> 2ND FLOOR: 3RD FLOOR: � <br /> /LT'(.:; 5g 0 Review Location Survey <br /> and available options <br /> ESTIMATED CONSTRUCTION COST: -► ♦ -i ♦ .♦ ,;,, 1 ,; -. <br /> (Please round to nearest dollar) <br /> 0 Yes [►r No ❑Don't know <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? <br /> es LI No ❑Don't know <br /> 2. There is a wetland or floodplain on or near the property? <br /> Li Yes LI Nb <br /> 3. Have you talked with the township about your project? <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? �ave blank rfonone) <br /> 5. This project is associated with a rezone/CUP/variance (petition/appeal# ) Yes CNo ❑Don't know <br /> 6. Is a location survey required? ❑Yes 43-No <br /> 7. Is this correcting a violation? <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -). -► <br />