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i. <br /> i <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> (1(TS/1/X_5 /Y14D Cr'T ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 7� CJ5 f'I" Re c. L C crrJT�it e.-�� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS i. <br /> . d ; G V -iitor ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> R t C k A9/4-0-1-1_ .J ('.,,, 6/1 E€L S s '-s LI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> IUaWi2o.3/S /l/) 5 44-, E <br /> (City,State,Zip) S3 (City,State,Zip) ❑ Setbacks f <br /> P( cat L./f s. CE -rei.tt.,c <br /> PHONE PHONE A� ❑ Site Plan approval from <br /> 60g-- 6 6 if"v g 60,F 6 c/7 --?Eau applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. _ <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> '/a: '/a'/a: ❑ Driveway permits <br /> ADDRESS: nn (state,county,town) }' <br /> 4d Yh /) 4 ( 2 0 ❑ Sanitary permits , <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> I <br /> PROPOSED PROJECT INFORMATION t' <br /> PROJECT DESCRIPTION: ` <br /> LL ,,,,,,,,, . ,, ,,,, -,‘, <br /> . ❑This project is a new building or structure. �� 1 <br /> This project is an addition/alteration to an existing building or structure. ��`�@" <br /> ., 1SANITARY SERVICE: PERMIT NUMBER: :��� ��€� ` ` ''„ <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> :W .... <br /> AREA TO NEAREST SQUARE FOOT: ti <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> 4 TOTAL SQUARE FOOTAGE: 4 �m <br /> F h a <br /> 2ND FLOOR: 3RD FLOOR: ' �� � . <br /> -,y i. ,\te _ <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ I I'd 0 0 , \ <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 7 Yes ❑No ❑Don't know ( <br /> 2. Is there a wetland or floodplain on or near the property? Aral Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? LI Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ,)Yes ❑No t <br /> y <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 4 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED t <br /> (Continue on Back) —■ <br /> 545-112(aiga) <br /> i <br /> r <br />