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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O NAME i //J <br /> /�Gi''!� 074 ��/^F/ -X-- ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 3 913 a 56.i.a a 04 ae3 V£,R-o 4 t,-ix.- 52s 4 3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> o$ 313 'PO/ 946"- B.0 gee-1K-& 46 / C#W1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 3 9.A-r-0 cr 12 WY— ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City, e,Zip) ❑Setbacks <br /> S-i."` C.. <br /> PHONE PHONE ❑Site Plan approval from <br /> 5.-tte.,t applicable township. <br /> E-MAIL ADDRESS E-MAIL DDRESS <br /> .4',ys41,- ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL p frontage drawn to scale. <br /> NUMBER 038/O*48—IQs'—yob}.O — ' /• <br /> TOWNSHIP: SECT• : <br /> Taw0• of ni Ibol✓E.TasJ 1/4: 1/41/4: ['Driveway permits <br /> ADDRESS: ' - --, (state,county,town) <br /> 3 4.S A .S,...ws.>O 1240 V 1,- A wT 53 59 3 <br /> CSM: LOT SUBDIV.ION BLOCK/LOT ID(public, permits 14. G ad,1,am (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 1D 6--c-it- ❑ Zoning District <br /> . ['This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existi g building or structure. <br /> SANITARY SERVICE: PERMIT UMBER: ❑ Rural Address <br /> EWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: 'NUMBE' OF STORIES: (Not including basement) <br /> ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> I <br /> s0A- ❑ Review <br /> R vi w OCatnry <br /> S urvey <br /> y <br /> ESTIMATED CONSTRUCTION COST: and available optio ns.ag- <br /> (Please round to nearest dollar) —00. -► -., --$. ♦ ♦ $ -7 v U <br /> 1. <br /> The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 1E1Vo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dikes OW ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Sales E o <br /> 4. Has there been a zoning permit issued for this pr perry in the past 5 years? Yes EINo <br /> 5. Is this project associated with a rezone/CUP/vari nce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Dies 2 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes VA o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -► <br /> 545-112(4108) ,_ <br />