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3 � <br /> s4 <br /> t SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME A — <br /> �IfZ • . .4 �tGKsv-r /ki 97I .K AJTo 674,,, Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> o t 4• 1 L�-t✓ 'tE�'�V Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 608'274 -Z•' ' IN•A C141. • Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION - d includes dimensions <br /> AGENT NAME CONJRACTOR NAME <br /> t.,�% 4-1,iA. r{ e , Gp • E ite Plan including location <br /> AGE ADDRESS CONTRACTOR ADDRESS {� - _ of well/septic <br /> �r�e1 {�O i T T <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> " Nta4l wt4-, '41 . 531I°J <br /> PHONE PHONE ,Site Plan approval from <br /> Pe) ' $33- 3 Z I pplicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> w • V I+4 Res SitL€2 •0,pi[�1 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) TTY) <br /> PARENT PARCEL NUMBER: ,( CURRE ZO ACREAGE: Ievation of property <br /> El NUMBER 0109-3(PZ-42.13-4 � s q ontage drawn to scale. <br /> TOWNSHIP: 1 S CTION: ` / <br /> i ' o-- 1 1/4: N W 1/a1/a: S w nvewa mits <br /> ADDRESS: state,c ,town) <br /> —3 cz)- -- \,—I - R—e- i-I-1,,,_,_CSM: LOT SUBDIVISION BLOCK/LOT 15 <br /> •F'Janl -rmits <br /> - (publaivate) <br /> • <br /> PROPOSED PROJECT INFORMATION i°i <br /> PROJECT DESCRIPTION: \ <br /> IIZOO 4T. WieoWei DOSt/ 1'a14.46/5 APprr'CI4 1 District z <br /> a <br /> ❑This project is a new building or structure. ? <br /> This project is an addition/alteration to an existing building or structure. F;.� a <br /> SANITARY SERVICE: PERMIT NUMB ea dr6 y ' <br /> EWER 1EPTIC �/ (new! va <br /> HEIGHT IN E NUMBER OF STORIES: (Not including basement) 'U '"` <br /> AREA TO NEAREST SQUARE FOOT: , ' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: / 1ST FLOOR: e , �l 1tt <br /> J� / \ Q Q_ 4, TOTAL SQUARE FOOTAGE: + � 2s T" rbance 7 <br /> 2ND FLOOR: // \\ 3RD FLOOR: <br /> ) oo 0.0 <br /> (Please r ED CONSTRUCTION)COST �� -, o <br /> Please round to nearest dollar <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EgNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Rio ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? I 'es No <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 none) <br /> 6. Is a location survey required? (see reverse) Ekes n o ❑Don't know <br /> 7. Is this to correct a violation? DYes Zi o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -► -► <br /> 545-112(4/08) <br />