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SUPPLEMENT to Web App <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION , t.,.. CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> tkout/0-- /A. ctAA-.0 -- <br /> /N Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Z 2 seed Restriction; CSM _ <br /> -i`lly 5kiI0h RD I) e �0res� ,.5 333 Variance(# ) /)f <br /> HOME HONE CELL PHONE E-MAILADDRESS <br /> 6ev —Atai-13)-1 'Site Plan drawn to sca34, <br /> AGENT INFORMATION _.'., ,4 ;CONTRACTORJNFORMgTION ;i and includes dimensioA �I <br /> AGENT NAME CONTRACTOR NAME ,\�,n Site Plan including loc ,�.p AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) j l Setbacks 3 0/2-5-40/5-0 <br /> PHONE PHONE 0 S-Ite Plan approval from t I <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / Floor plans to scale <br /> PROPERTYILOCATION INFORMATION_, °(http el/accessdane.co,dane.i41.us/) Elevation of property <br /> PARENT PARCEL NUMBER CU RENTZ NING: ACREAG <br /> ❑PARCEL 0�0 _ Q (,_Q 76�� eY t S� frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECT N• �° iv <br /> 6 ,,,-K,.., ( � '/a: J 6 ,RA: Driveway permits <br /> ADDRESS: (state, county, o, • <br /> CSM: LOT SUBDIVISION „Sanitary •- ■•• s <br /> g +aBr77 (public jar <br /> PROPOSED PROJECT INFORMATION - v�{ STAFF REVIE , <br /> PROJECT QE'CRIPTIOt�;� 1 c x 1 OC <br /> 0 G7,) pt. r p(• Zonmg Dl act 1� <br /> s -lW ADS <br /> his project is a new building or structure. Us 4I ` � <br /> �eTmltted USe s4 <br /> al project is a -dditi•. - era,on to an existing building or structure. x �,L� } '‘oc <br /> SANITARY SERVICE: PERMIT NUMBER: I Rural Ad a SS ;t -- _ <br /> ;TM=s i ^i : . <br /> [)EWER OEPTIC ; • (neW 1,4, <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) Z +* ',/ <br /> 1.2-. 'E Y `c6 epIaIn; I? <br /> / / Sho B art. ttachimept) <br /> AREA TO NEAREST SQUARE FOOT n f <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) " t -� :: <br /> BASEMENT: . 1ST FLOOR: t::--:-.-.��C��������.I•��C�It�: :�x�` <br /> Z 4, TOTAL SQUARE FOOTAGE 1 S i3]3BS UTB C1r-1 h�T. ;- k <br /> . laacc 4'57„.„..„..c., t <br /> 2ND FLOOR: 3RD FLOOR: Z g C _ ,Ft . . <br /> o f <br /> A1 Rev Ll a PP S EA+- <br /> ESTIMATED CONSTRUCTION COST: k <br /> tID d � abieons, <br /> (Please round to nearest dollar) -∎ '"� "♦ "♦ "i ♦ / � 7 , a g', <br /> • <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? Efres ❑No EDon'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? Eves ❑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) Des ❑No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -' -0 --0 <br /> 54S-112{4/OB) <br />