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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME, �/ <br /> '3 ti( �1( / 1 1 V /-1 L i 1 -Y i Gil i f 1 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip)n / i,,I 1 Deed Restriction; CSM <br /> i-139, W�a 7CL)a tC/, V I flCtS C�, L.1� 535 !8 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> g (0-.E C <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> To k ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> ad 9)-)(95,9, applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> j PARENT PARCEL, UMBER: CURRENT ZONING: ACREAGE: El EleVatlOn of property <br /> /I1 NUMBER 0(pgDC\\°-2° 1Z--(O a3-0 1\- gil 1 (oe K C; , ,'j frontage drawn to scale. <br /> TOWNSHIP; SECTION: <br /> W//CSo I- ____ca_____ 1 4: 1/41/4: 3E- 0 Driveway permits <br /> ADDRESS: (state,county,town) <br /> 1-1'))(0\ LO ix1 in M ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> STAF <br /> F REVIE <br /> PROJECT DFCra'PTIh : q <br /> _.q>� X b C I ❑ Zoning W <br /> District <br /> . , This project is a new building or structure. ❑ Permitted Used <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address s <br /> ( <br /> SEWER ❑SEPTIC new/exlstling l E l <br /> HEIGHT IN FEET t9 ( NUM BER OF STORIES: (Not including basement) <br /> / ❑ Wetland/Floodplain/£ <br /> Shoreland (at chment - <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> Li EosieonCoittrofpermt <br /> " . <br /> BASEMENT: '1ST FLOOR: l t5 2S TOTAL SQUARE FOOTAGE: j (Sops,dsurbance s; <br /> filling/access} <br /> 2ND FLOOR: 3RD FLOOR: ; <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and av011aflCe'OptiDnS <br /> (Please round to nearest dollar) -"∎ ♦ -► --► ♦ ♦ /O na . <br /> / f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes t'No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes dNo ❑Don'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? ❑Yes ZINo <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 dNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'No <br /> 14 O APPLICATION MUST BE SIGNED <br /> 545-112(4/08) �� (Continue on Back) —► -+ <br /> 7o v <br />