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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 5-1e'J e t 1-1nn AA y S Ps t■Ic v ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> �b I c ST� Deed Restriction; CSM <br /> }{16-I-i w/}`/ 73 Variance(# ) <br /> HOME PHONE !CELL PHONE E-MAIL ADDRESS <br /> 608 -WI- —CO 1 Z ! S'U A nf5+.,nt 2) Sr'AL-ESft J Z 1 WM ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> 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 /> ❑NUMBER O Z Vo-r'Z �43~ c`Z I .$� frontage drawn to scale. <br /> TOWNSHIP: SECTIO : <br /> DEE2t ELD '/4: ,/4,/4. ❑ Driveway permits <br /> ADDRESS: y y (state,county,town) <br /> t 6/Ss S4 4 �I'R Lioeti T 3 ❑Sanitary permits <br /> CSM: LOT UBDIVISIOI� BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTI9N: <br /> POQCA-( (Fra,,,OT) M a D)F< <.4-10^) ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> 121This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: [ p, 1/ r V NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <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: ❑ ErosionControl permit <br /> /( 0 + TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> fI 0 12 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ --0. -01. r S J and available options. <br /> (Please round to nearest dollar) l <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# i9k )' (leave blank if.n'one) , <br /> 6. Is a location survey required? (see reverse) <br /> Des ❑IVo' ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ,•— <br /> 545-1 12 14108) <br />