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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 /> m /-gy L R 1\)6. 12._ ['Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 3a& S-f;,JNE-55 A V _- , 171/CFA2L,4)(nt ' 5355 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (0O''— _ I, - — ',c)r) MLA - • e L PLAcRe.ccit 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 of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL d frontage drawn to scale. <br /> NUMBER d 1) - J 5a-o803 y I�' c/ <br /> TOWNSHIP: SECTION: <br /> 8 Loom I ry 6 6(2-0 V 1/4. ,/4,/4: El Driveway permits <br /> ADDRESS: (state, county,town) <br /> 3388 Z-,�N _55 AVE, IAA. L S 3CJZ ❑Sit Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> l 1- / -P2�t_ 1/4,-k[Li (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Pu T PO L. S eiC ry e vT TD 6 AA GF. ❑ Zoning District <br /> . EIThis project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER WIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> 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: <br /> ❑ ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> D-8QQ filling/access) <br /> U ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ S r 6 , vv and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Do ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'ales ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 'lo <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 �Vo EZDon't know <br /> 7. Is this to correct a violation? ❑Yes a. <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />