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- s'SC _- W., <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> E <br /> OWNER NAM1` e <br /> �05 r, !1 a, Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street.City,State.ZiR) Ir-i Deed Restriction;CSM <br /> 3Z-18 6,..xxt(aryct_c+(c J e, CI t Sow .1 5 3 70 / Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRES <br /> ®' 576-kr 8 2.5 B54-6,A6ts 9 e x� . c.o Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> T'o.�.($ av�. .ro - 'Site Plan including location <br /> AGENT ADDRESS ADDRESS of well/septic <br /> 3 Lt 8 6.Akoc((o� .�ok Ci r— . <br /> (City,State Zip) (City,State,Zip) Setbacks <br /> /'1o�d sso.\ /--/Z 537°41 <br /> PHONE PHONE Site PIa val from <br /> I(oB) 376--'8 Z5 ppli ownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 8 4..1,,,,L jci>a >>cv,--1 fifTloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn [$ Elevation of property <br /> PARENT PARCEL NUMBER: A7 CURRENT ZONING: ACREAGE:C !� P P rty <br /> ❑ NUMBER VaIt3-0.8 '-7JLt0 4 C- 2 �, 6'� frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> f.6,crI2e_ 1/4. /4�/4. Driv ermits <br /> ADDRESS: (st ,co ty,town) <br /> 4 3 20 j-{o c p kut- d. <br /> CSM: LOT SUBDIVISION BLOCK/LOT p Ic, ovate) 'ror`-� <br /> PROPOSED PROJECT INFORMATION <br /> PROJ T DESCRIPTION: <br /> 5+ee.( 1 .,2 3,,t' '�i1 0 Col' L„,•,I M '/®4- I ® i � , ' <br /> This project is a new building or struc ure. : es i',� <br /> �fl This project is an addition/alteration to an existing building or structure. ; -� <br /> SANITARY SERVICE: PERMIT NUMBER: 'i-i +- - <br /> �- ❑SEWER � <br /> SEPTIC I 81 L-1 � � � � � �y a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: \ 1ST FLOOR: <br /> (-10 i 40 ' 4, TOTAL SQUARE FOOTAGE: �� ∎� € T���� <br /> 2ND FLOOR: 3RD FLOOR: X V <br /> ESTIM ED CONSTRUCTION COST: ,'rs ,:� <br /> (Please round to nearest dollar) C - ,, _ . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes I No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I?No ❑Don't know <br /> ,--3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> r-4. Has there been a zoning permit issued for this property in the past 5 years? grYes ❑No Z P2o0 9C)0 22 <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 RrNo ❑Don't know <br /> —7. Is this to correct a violation? ❑Yes R'No <br /> APPLICATION on BacMUk)T BE♦ -SIGNE► '- <br /> 545.112(4/08) <br />