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• ii 6C)4 SUPPLEMENT to Web-App I <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> ` PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0111 NAME <br /> � <br /> ' lc�S G � , Zoning Status;CUP; <br /> ESa ;Number.Strepet.City.State.Zip, /� Deed Restriction;CSM <br /> 3? / isr,/�Fe e d. s.H Ate, ,./ 1 I-' ' 53 5X7 Variance(# ) <br /> HOME PHONE ;CELL PHONE E-MAIL ADDRESS <br /> S3 2-.sci sc, (`j i 206 '`7/0) (irr. ,/. tour›, ' . z'.CC' 0 Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1 <br /> City.State.Zip) , City State.Zip, Setbacks <br /> PHONE _ PHONE \� 4`► itelPla prove{from <br /> ` .ppli I township. <br /> E-M.AIL ADDRESS E-MAIL ADDRESS <br /> door plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING ACREAGE: Elevation of property <br /> 0 <br /> PARCEL 0ilyi s0;G{!/ - v ,f—/ /#0812 frontage drawn to scale. <br /> TO'^�'NSHIP SECTION <br /> &y/ 05 35— '/a: .VW '/%: iii ivew ermits <br /> ADDRESS Q (sta ,co nty,town) <br /> 3.251 ,( .,r re Rdi - Sanit rmits <br /> CSM LOT SUBDIVISION BKiL0T <br /> E:)..4-e. C()As. �sa`i�: (■^ (publ' ate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION I <br /> - �f // 'i f o. v e t. r ks/>Up /X L( oning District <br /> ❑This project is a new building or structure. Permitted Use? <br /> SI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMFjER. -iral ` +' " s <br /> J SENDER 4 SEPTIC <br /> NY A (new r-xisting) <br /> HEIGHT IN FEET NUMBER(.F STORIES )Not including basement; <br /> J S / WetlBrrti1F1E1Otiplattt <br /> / Shoreland (attachment) <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 /> rustonc ntroi permit <br /> X 1 J.(1 , TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> an tanttas <br /> 2ND FLOOR 3RD FLOOR <br /> lzi Cl/ eview Location Survey` <br /> ESTIMATED CONSTRUCTION COST: ♦ __ __ ♦ ♦ r and available option. I <br /> (Please round to nearest dollar) 3 i <br /> \i ti sA <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Tg No ❑Don't know❑ Sj fy,/ <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IS No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Y.<LJ No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes U No <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) LI Yes U No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ('No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -1 -1 <br /> 645-112(4(05: <br />