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. • Al/C7-)-1- <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> OWNER ADDRESS (Number,Street,City,State,Zip) seed Oning Status;CUP; / <br /> Restriction;CSM <br /> Lib\�l k\- y —13 c etcc , yY 5353\ cz, Variance(# /CC'0— ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> -- ((A 332.-1(12-8 So"C,s\Nes@\"-\‘-evv, iC-‘Z, ‘.qC 0 Site Plan drawn to scale <br /> AGENT INFORMATION ' CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAM �1 <br /> G 'V,Q es. d Site Plan including location ,' <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) 1\ , A ity,State,Zip) [dSetbacks C f, �;U <br /> I ecev.k ,�\ S�S3\ �c ,lit Z' <br /> PHONE PHONE \ Site Plan approval from <br /> ( (opt) 3 — Q- applicable township. NT <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PRO PERTY/LO CA ION INFORMATION (http://accessdane.co.dane.wi.us/) � <br /> PARENT PARCEL NUMBER: _ CUR' NTZONIN_ G' ACREAGE: ❑ Elevation of property !1 <br /> ❑ <br /> NUMBER <br /> BER LY2`1 -Di(L-161-cl' 6°..' •2.-_ ��' (,' frontage drawn to scale. <br /> TOWNSHIP: CT•N: <br /> i /t/t 1/41A: d D . way permits / <br /> \ o l,� 1 �4: �4�4: <br /> ADDRESS: \� tate county,town) V' <br /> ' Sanitary permits • <br /> `- CSM: LOT SUBDIVISIO BLOC T <br /> �� (public,private) <br /> rnuruoEu rsUJ CT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: [ ' <br /> e u3 - ,V\ ❑ Zoning District <br /> This project is a new building or structure., ❑ Permitted Use? \,/ <br /> ❑This project is an addition/alteration to an exis• bui • structure. <br /> SANITARY SERVICE: P RMIT NUMBER: pp ❑ Rural <br /> ❑SEWER EPTIC 4l1 2 3c, •— �`tA. ` (.z."...T tt (new/ xisti ) <br /> HEIGHT IN FEET: NUMBER OF ST RTES: (Not including basement) <br /> ❑ Wetland/Floodplain/ . <br /> .reland (attachmen <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ■BASEMENT:, . 1ST FL R: ErosionControl permit <br /> �F �-\ �� ,9 a ( L=',)1 L�,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance,` <br /> '1.47 <br /> 2ND FLOOR: 3RD FLOOR O filling/access) �� /, <br /> 5S kf - i (-Z)/i <br /> �` . eew Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �f ^r1 u and available options. <br /> (Please round to nearest dollar) S V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ja No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ,4No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 4YeS ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 16 No <br /> 5. Is this project associated with : rezone CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? -- reverse) ❑Yes 'No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes A No <br />