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-)-c)- x 7,c_-_-)- i/ .-- --1-So — 6)-W <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 51J� 145 oning Status;CUP; <br /> OWNER DDRESS )Number,Street,City,State,Zip) Deed Restriction;CSM <br /> Zfi Oa fl! N rrtg✓►ti �D <br /> - /11c r}}gLNQ1)/ ....C3-55-4 Variance(# ) <br /> HOME PHONE :.CELL PHONE E-MAIL ADDRESS <br /> 83ig-- I3 /8 (0-D' ,r! '. 1..'"3c4sl o..."-".3 & Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> A NT NAME CONTACTOR NAME A/co AGENT ADDRESS c,C�) CONTRACTOR ADDRESS �well/septic i including location <br /> //9t(,s ri Rt C_ 5T- 41(5 <br /> (City,State, ) (City,State,Zip) Lx Setbacks <br /> plc.69-14 t 5 3 cSSt5 fit cp.e c,lipt"YP. 5.3575-g <br /> PHONE PHONE a Pla approval from <br /> e 3-- O 3/ , t1,315 - /3302) app• township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ,/ <br /> L� Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONI G: ACREAGE: P p y <br /> ❑ UMBER 0 COi01)Zel E3/n L --Z '5.-- frontage drawn to scale. <br /> TOWNSHI : SECTION: <br /> Dc,`� // 1/4: N W %oh: /l) E riv ermits <br /> ADDRESS' (State o 9-y,town) <br /> 2'7 e Z /iZnPe"' -A a ry 'rmits <br /> CSM: LOT I SUBDIVISION BLOCK/LOT <br /> (pub' , ivate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> gEt4.71—N• R r sloif6: /-ft'b/Shia Ind District <br /> . isibis project is a new building or structure. pfiergitted Use? <br /> L7 This project is an addition/alteration to an existing building or structure. i <br /> SANITARY SERVICE: - PERMIT NUMBE • L TAddress <br /> SEW SEPTIC (ne s: <br /> HEIGHT IN FEET NUMBER OF STORIES: ( of including basement) <br /> I / 51-01Z"7 Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) we - <br /> BASEMENT: 1ST I F OOR: ro nC trot permit <br /> J S qC� TOTAL SQUARE FOOTAGE: + (Slop disturbance, <br /> 2ND FLOOR: 3RD FLOOR:(' CS / fillln /ac @S5� <br /> i 2 0 0 Review L. catio Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ v Q and a options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 2 l No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? iii-Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? C1 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ®Yes J 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) Ll Yes No Ll Don't know <br /> 7. Is this to correct a violation? ❑Yes allo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -+ <br /> 545-112(4/08) <br />