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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 A G <br /> ' tie l/E A 1..r-14:77..- Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> (#' (.. O■/v4-/)'0 _ Jr4Q Q iE 2+FS_ <br /> (ti L S .1iSTL- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> y –, t- _ y , , , _ ❑ i e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME" <br /> 5Aph1r---- 'S-,Ary ,F - ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ pile Plan approval from <br /> \,/applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ dor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: eV tlon of property <br /> ❑ NUMBER (7(dd1D910.--. 14 -613o—SECTION:g R--\ 0,5c-'8- frontage drawn to scale. <br /> TOWNSHIP: <br /> IV i�4' ;bQ a\ '/4: 5 iE '/41/4: 5 . U Drive y permits <br /> ADDRESS: (st ,county,town) <br /> ob L d 6kf7 5Th — ❑ Sanita permits <br /> CSM: LOT SUBDIVISION <br /> BLOCK/LOT (publ• ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> •• -- ting�i �,lstri F <br /> . 4'fhis project is a new building or structure. <br /> P 1 9 fitted Use-,,,'s <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: "Ant a <br /> ❑SEWER ❑SEPTIC (ne existtn <br /> HEIGHT IN FEET: !/ NUMBER OF STORIES: (Not including basement) �0 0 I <br /> 1 of (afifacment <br /> AREA TO NEAREST SQUARE FOOT: ,r,,. <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR ❑ ECOSi a+°+Jltroi Permit Ff <br /> �D j TOTAL SQUARE FOOTAGE: ,, (Sl s S, •isturbance, , c <br /> fillingfac *07 e <br /> 2ND FLOOR: 3RD FLOOR: , <br /> t irr <br /> evie to Survey <br /> ESTIMATED CONSTRUCTION COST: art 4k bte o(7tlonS <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ (050 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1,�a/No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Ja No ❑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 F.No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank)none) <br /> 6. Is a location survey required? (see reverse) ❑Yes NNo u) <br /> 6. know <br /> 7. Is this to correct a violation? ❑Yes 1a No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —* —► —P <br /> 545-112(4/08) <br />