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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Nrkiaj � <br /> ■ <br /> l SardeA Son()ex b-e43 ❑;Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> T1 5n-)t -k bath k ROI . Cqrnbr .I 53523 Variance(# ) <br /> PHONE HOME CELL <br /> P I- ,I i-1 10.g oa5-110l b55on <br /> bar 0..."mcz)I . c--3° ti Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS Qi well/septic <br /> (City,State,Zip) (City,State,Zip) at Setbacks ' <br /> PHONE PHONE ❑ ite Plan approval from <br /> pplictable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) 111 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACR AGE: I`>-u P P y <br /> ❑NUMBER 01(n)c cola - I _�3ov-9 A I (EX) 4 o-I� frontage d to scale. <br /> TOWNSHIP: SEC yON <br /> C" /Y /Si i an o, 1��VV 1/a: y4%: +�- ❑Drive ay permits <br /> ADDRESS: <br /> �1 _ I' ��++-� I _ C (st e,c0 ty,town) <br /> qia SiVll bad Rd C 1bi1�1�(e-, 5 .3 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION ...111 BLOCK/LOT ( (pU.$Ic,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> `a X a 0 Garth S hei01 / el0,1 .e.. Zoning District <br /> . This project is a new building r structure. <br /> emitted Use? <br /> This project is an addition/a eration to an existing building or str cture. <br /> SANITARY SERVICE: PERMIT NUMBER:IN kurai Address <br /> EWER EPTIC r Flew/existing) <br /> HEIGHT IN;EET, NUMBER OF STORIES: ( duing basement) �1lVetland/Floodplain/ <br /> •'� '�O }��� `` 'Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �\ Eropes,disturbance,ntrol permit <br /> /�/ !1 j TOTAL SQUARE FOOTAGE: 4, (slopes,di \iti <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ^ r�� <br /> (^y/`/']/ Review Location Survey1 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► --► $ ` �\ J0 O� and available options. V <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des dNo ❑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 �No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? CSIsiies ❑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) Ekes /No ❑Don't know <br /> 7. Is this to correct a violation? :Yes 6 N o <br /> APPLICATION MUST BE SIGNED,______ (Continue on Back) —, -i <br /> 545-112(aloe) Cg ' <br />