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-';SUPPLEMENT toWeb•App;#, <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION :,. _ ': CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ' gr �, c hrrI Zo • g Status; CUP; <br /> O R A.DRES umber,Street,City,State,Zip) ed Restriction; CSM uv) n \� �C Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS I <br /> �C q q 766 f �` `vco nv'- t� ""1-6 0 ' C- Sit Plan drawn to scale <br /> AGENT:INFORMATION �;, CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site n ' cluding location <br /> AGENT ADDRESS CONTRACTOR AD ESS • of ptic <br /> (City,State,Zip) (City,State,Zip) etba s <br /> PHONE PHONE • Plan approval from <br /> applica le township. <br /> E-MAIL AD• SS E-MAILADDRESS <br /> F or plans to scale <br /> ;PROPERTY/LOCATION INFORMATION-(httpe//accessd On- e co,drane*Lilo_.. Elevate property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACRE E: <br /> El NUMBER cc./Q f44 si 4S1 IR- 3 . fr e yawn to scale. <br /> TOWN, iIP: SECTION: <br /> ��J 1/4: ,/4,/: 0 Dr a ermits <br /> VA`'1 (sta unty, town) <br /> ADDRESS: ,o <br /> 3`-I of O�Q)J / k_ I)r <br /> 0 Sani1- permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (. - private) <br /> PROPOSED PROJECT INFORMATION . . gs ST F REVVIEW . <br /> PROJECT DESCRIPTION: J ` p • 5a `1 �` , � " re <br /> Ref/AC e_ '61'1 A Je 'h d S 4. ge /0'ez t '" ;'D {osio ,we t <br /> •/ erA it. 'il ag' ,"`'`-° 'tom . r <br /> . QThis project is a new building or structure. . %bit'"`' • rmlfted Used+ <br /> This project is an addition/alteration to an existing building or structure. _ 1 �3 <br /> C� Tit gtares5 <br /> SANITARY SERVICE: PERMIT N MB R: ;r <br /> SEWER [)EPTIC 4• ,111.1- e:.- Ig !-� 2: <br /> HEIGHT IN FEET` NUMBER OF ST RTES: Jot including basement) 4 ti+Mi-A _. • <br /> . . ) , S . • }W- sib/p.loo_gla§nf v j"`. <br /> ofe a . ttaclme(1t) <br /> AREA TO NEAREST SQUARE FOOT: } -t '' W <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) �f <br /> BASEMENT: 1ST FL O : 9 �� �?,e!C 1:4- J <br /> S4, TOTAL SQUARE FOOTAGE ,j, -, "...„. b'- lJT C,;y ft..„ /6 <br /> 2ND FLOOR: 3RD FLOOR: �a _'� g "-. 1y <br /> S <br /> ESTIMATED CONSTRUCTION COST: evict.,Lo ad n S1J1 e�/, , <br /> (Please round to nearest dollar) a 6 ,nF <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es QNo • QDon't.know <br /> 2. Is there a wetland or floodplain on or near the property? Eyes f No QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Bres QNo _ <br /> 4. Has.there been a zoning permit issued for this property in the past 5 years? Eves QNo . <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) QYes QNo ['Don't know <br /> 7. Is this to correct a violation? QYes ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-19 2{4ro9) . <br />