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, <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / <br /> �Go f f I.C.15 2-ECA)S fc- I ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 1�'77-"' Deed Restriction; CSM <br /> BSI , rr k Cross Pice i4 5 WE e.S 3 Q variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 7 8 •J.% ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME II_ <br /> Cre5cv <br /> e , f3 <br /> k U)'cicS TA C ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 6s Ber-cde1/o CI- <br /> (City,State,Zip) (Ci State,Zip), Setbacks <br /> Cross oss isin S C1.1' c"3,96 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 605 27E 3 c5o applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Yes I Ck:, /...st- ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.ciane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL t-��(0)0y_�,3_�l10-0 P (' frontage drawn to scale. <br /> NUMBER 1.f7�/ (-/ ! l <br /> TOWNSHIP: SECTION: <br /> G 1/4: 5,..) %I,: S� ❑ Driveway permits <br /> Ci-o ��cf t�S (state,county,town) <br /> ADDRESS: r <br /> &Si Bc'f r C ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> ZO ,7 A EU- (e .4. : � <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: " a <br /> Zoning Distrie 4Yj � r /31-71-1j d F rrJb n V nv 1 W W 1 ❑ n ,,, : <br /> ❑. ❑This project is a new building or structure. `Permitted <br /> Use? <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑,Rural Address <br /> ❑SEWER rS-EPTIC (n eW/existing) <br /> m <br /> e <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Flaadplainl <br /> ' Shorelarid (attac meat) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ EroslonControl permit <br /> BASEMENT: 1ST FLOOR: ' <br /> ,, TOTAL SQUARE FOOTAGE: ,l (Slopes,disturbance, <br /> filling/ac <br /> 2ND FLOOR: 3RD FLOOR: ess) E <br /> 1`T?9 ' <br /> Q.Review Location Survey ` <br /> ESTIMATED CONSTRUCTION COST: / °C and available options <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ . <br /> f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? UYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 0 N <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? gtfes Erg-o- <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 Eric).—a No CI Don't know <br /> 7. Is this to correct a violation? ❑Yes <br /> 1 ° g APPLICATION MUST BE SIGNED <br /> 5- -C1 (Continue on Back) --► -► -* <br /> 545-112(4/08) <br /> - 5-, s <br />