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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 " ^n <br /> ��j1e� q- I.(J,QY4 l l ' I l leg— n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street, <br /> CityState, ip) Deed Restriction; CSM <br /> V qo ki, Cv � ,SE A-/, ,�1 14 -Vo ) _L Variance(# <br /> ) <br /> HOME PHONE CELL PHONE AD-MAIL <br /> g41-517-o 7-73 -OB o2 Vsrn C jleic& 1- czNA. n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> (iUQO_ Y RRJ1 ( ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> $i/ 3, Brcx)) I I�Y. <br /> city,State,Zip) (City,State,Zip) I ❑ Setbacks <br /> tQG'14 ')c (,0] 53 .1 <br /> PHONE HONE s, n Site Plan approval from <br /> bog-133 L - 1 4S0 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> m+a rra A4_�t.0©"'lU t_,ec f v ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION _(http://accessdane.co.dane'wi`us!) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONIN ACREAGE. <br /> ❑ PARCEL ^4/' /CI/ � SZs� (�_ 3 S frontage drawn to scale. <br /> NUMBER C� 1\ <br /> TO SHIP: SECTION: <br /> ears an 6pr�l e y , f \ ,/4. N C ,/4,/4: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 2a 13 I/Ok lk -Powk+ br • n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION ` <br /> STAFF REI � - <br /> Y„ - , <br /> PROJECT DESCRIPTION: A � ,, L �'�, �.:�'t'' � � <br /> / (o t ® 013IF19 5�� xr <br /> . This project is a new building or structure. �t <br /> ❑This project is an addition/alteration to an existing building or structure. _� ��,,SANITARY SERVICE: PERMIT NUMBER: XS ° r-t '"do .es 4� '; <br /> iSEWER SEPTIC �/ :ne e us F 4� <br /> JJJJJE "'''"'''' a <br /> HEIGHT IN FEET: NUMBER OF STO IES: (Not including basement) E _ .. . <br /> Wet an e tP.6 taq0 a t.'-g <br /> .aiore an c; thipstimelltr: <br /> AREA TO NEAREST SQUARE FOOT: 1 . _, ? �,.e <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) _TOSton('ori <br /> , ----0-,.0.- <br /> ,o .. . <br /> BASEM T: 1ST FLOOR: : 5 5. <br /> j TOTAL SQUARE FOOTAGE: 1 s�e"�5(7®e �1S � ,eanc ��f <br /> r-)- ii I.6,e a ® SS A ` <br /> 2ND FL 3RD FLOOR: r a J ,; <br /> ESTIMATED CONSTRUCTION COST: - <br /> (Please round to nearest dollar) --► -► -+ `J ��` `' ,` <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? ❑Yes No 0 Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? iYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eyes 2No <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑YesNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► .-■ —► <br /> 545-112(4109) <br />