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3 , <br /> SUPPLEMENT to Web-App # <br /> • <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> e !, sit..0A 74S ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,C. ,State,Zip) Deed Restriction; CSM <br /> WO ( C.�A %C s? /� Variance(# ) <br /> HOME PHONE CELL PICNE E-MAIL ADDRESS �/ <br /> 4 3 , 1 L'n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NA E CONTRACTOR NAME <br /> 1ee//S474( 0",(4 r-/ rh `� <br /> Li Site Plan including location <br /> AGENT ADDRESS CONTRiCTOR ADDRESS �[ of well/septic <br /> Cf4'�c �d✓CitI�ZO// , " "c'e <br /> (City,State.Zip) (City,State,Zip) i <br /> / / Setbacks <br /> PHONE PHONE/ e w' Jf07Z ❑ approval Plan lana roval from <br /> 71 Z ,''Y/ / cc applicable township. <br /> E-MAIL ADDRESS E-MAIL ADD'ESS <br /> /� e .� f� `,4 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) L`J tlevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL 07/r_p 3(_$7/0 - g_r 7Z- frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ''------ ' NE '/4'/4: S s-'J ❑ Driveway permits <br /> 4i co/4e '}/200 3 /4 (state, county,town) <br /> ADDRESS: _ <br /> V / �/7 Cl Sanitary yd�0 cs f4 �/`• permits <br /> CSM: LOT / SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> Zo <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C jo.t' ; 40 rat/�Ae ❑ Zoning District <br /> . ❑TT is project is a new building or structure. ❑ Permitted Use? <br /> L7 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER U SEPTIC (new/existing) <br /> HEIGHT IN FEET: . NUMBER OF STORIES: (Not including basement) <br /> i / ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> _$S,§_ -z i 0 , TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> __-— 2�� I ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: / /I and available options. <br /> (Please round to nearest dollar) ♦ ♦ --• -• $ /fJ, ow <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? CI Yes rJ' No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑JNlo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 91 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 10 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes L'No <br /> 6 <br /> � APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0 -► -♦ <br /> 545-112(4/08) O <br /> 19 <br />