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;SUPPLEMENT to;Web A004, <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY•OWNER INFORMATION , CUSTOMER TO PROVIDE <br /> OWNER N <br /> ,Tai / �f6, 0A �4444// �,)re-� Zoning Status; CUP; <br /> OWNER ADDRESS Street,City, t e,Zip) � / , ❑ <br /> '>&9 C� a( 1 _�f/ e— r-.' 5'- '7 Deed Restriction, CSM <br /> �. n�. 6—�Ok� e�, i Variance(# ) <br /> HOME PHONES ELL PHONE c c E-MAIL MDRE S <br /> - `8",f/ OZ2 r- p [ ( 4 64," ,v` ❑ Site Plan drawn to scale <br /> AGENT`INFORMATION . ;,. ;CONTRACTOR INFORMATION_ and includes dimensions <br /> AGENT MEN CONTRACTOR NAME <br /> Tef 1..-:-et A-5 ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS • of well/septic <br /> 70‘7 / /(C i t y, `fr Arat)(—'State,Zip) _ (city,State,Zip) ❑ Setbacks <br /> _I/, 1hs 6 ___ 5--- e77- <br /> PHONE PHONE ❑Site Plan approval from <br /> :.2 — 611./ applicable township. <br /> E-MAILA DRESS q f1 / /_in E-MAILADDRESS <br /> SeEf'T2-n a �5 'G/tiGQ, , c-c, ❑ Floor plans to scale <br /> ;PRO PERTY/LOCATION INFORMATION -(httpe//accessdane co,dan0*.ii5!) , ._ <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: 1� SECTION: <br /> YQ ./?Z� — 3 '/a: 1/a1/4: ❑ Driveway permits <br /> (state, county, town) <br /> . /jam ❑Sanitary permits <br /> CSM: ' LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF'REvI_EW <br /> PROJECT DESCI,TION: ,- { ''' <br /> V, ( Zk M golinalbistrictilWlwiV,t,:::a1WE:^;041•W§:i <br /> This project is a new bu or structure. y <br /> P 1 9 Li Permitted Uses <br /> ❑This project is an addition/alteration to an existing building or structure. 2 ��� 4 s <br /> 0 ura(Address <br /> SANITARY SERVICE: PERMIT NUMBER: }�}�, . ,� -�- ,.�,�33,4 <br /> EWER - [EPTIC l. aknew ISUpg) �. . <br /> HEIGHT IN FEET •NUMBER OF STORIES: (Not including basement) k K s � = '` <br /> QtWetlar�d/Floodplet <br /> } <br /> . ' f G Shote7an"d aac'ttaerlt) - <br /> AREATO NEAREST SQUARE FOOT _— a te , j i'` <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) "� �- - Ty 7 - ; <br /> BASEMENT 1ST FLOOR: ,-051D C0� pe n7lt <br /> 1 TOTAL SQUARE FOOTAGE j w ` SfapeS d1%7IT Snca, - ` <br /> . . . - k (irr1graGCeS� X r_ <br /> 2ND FLOOR: 3RD FLOOR: J) _ 'vim ,irT. e � <br /> paC/ O Re e aeattn SAY <br /> ESTIMATED CONSTRUCTION COST: is_ l ka <br /> -► =► -+ —► —► --o $ al a.) _ " nd a a abie pSlflns0k <br /> (Please round to nearest dollar) / a__ .R <br /> 1. The property s within 300 feet of a stream or 1000 feet from a pond or lake? es No ❑Don't know <br /> rty ❑Y <br /> 2. Is there a wetland or floodplain on or near the property? nY !o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if e) <br /> 6. Is a location survey required? (see reverse) ❑Yes o . ❑Don't know <br /> 7. Is this to correct a violation? [Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545.112{4/09) . <br /> • <br />