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' 1 1 SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> TSffd\ • .f/oW Wing Status;CUP; <br /> OW/ ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> V (�F t* -Itf4NC,‘,. C-A- O oN w l S/2 S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL Ap ADDRESS <br /> (fl. 5-- 7G ( R>it(lan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> okerip T NAME CTOR NAME <br /> IA j c /IJel 2 c‹.1 7u cK f/LS4 e Plan including location <br /> AGENT ADDRESS " CONTRA6TOR ADDRESS of well/septic <br /> S/8/y O4 �/ <br /> S0, Y /0/(7/ O/2i5,,,,) MIA ('I' T �� <br /> (C/' <br /> state,�rip) ^ 2 �d'Setb(City,State,Zip) acks <br /> PHONE C ` PHONE R8ife Plan approval from <br /> 374,_ G to Gam C-- s/6 6.(FEr G applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CU REN, ZONING: ACREAGE: ��feVation of property <br /> D PARCEL 0So9 1 1109 p S J- _ I e\ C frontage drawn to scale. <br /> NUMBER I <br /> TOWNSHIP: 45o,--) S 1I� 1�: N r � t4: S -J <br /> iv permits <br /> (stat unty, <br /> town) <br /> ADDRESS: �{ e <br /> ( f4wc it. -ji-rmits <br /> CSM: LOT LOT SUBDIVISION 1 I BLOCK/LOT <br /> is / <br /> PROPOSED PROJECT INFORMATION -STAFF REVIEW <br /> PRO ECT DESCRIPTION: INS <br /> I4 t( GA 12►L1S f -. ;<-3 0 ring District <br /> . l-This project is a new building or structure. rmitted Use's <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Ad• s " <br /> ❑SEWER ❑SEPTIC (new xisting <br /> e <br /> HEIGHT IN FEE / NUMBER OF STORIES: (Not including basement) <br /> 1 p /0 / a- e /FIoodplainI <br /> O AREA TO NEAREST SQUARE FOOT: r and z(attac tmernt) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> [[ Er le Control err tt <br /> BASEMENT: 1ST FLOOR: £ g <br /> TOTAL SQUARE FOOTAGE: ` (S,FO S,disturbance, , <br /> fill •f ssI� <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1)a 6 ' <br /> U Review Location Su <br /> ESTIMATED CONSTRUCTION COST $ CrO and available options <br /> (Please round to nearest dollar) - "� s rtrO - - ';,',f. <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 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 21Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes a 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) ❑Yes tit No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 43 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —o. —► —► <br /> 545-112(4/08) <br />