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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 ,, ll <br /> d`k lA 0a,Ac f)ct&eN S Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street, it ate,Zip) <br /> / O13 Fr-,-ft. d OCfOv. (,,',-5 53593 Variance Restriction;CSM <br /> � Variance(# ) <br /> HO E PHONE CELL PHONE E-MAIL ADDRESS <br /> )--13(0•40/ 4 45- 10 3 -&te Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 0W"e!— ate Plan including location <br /> AGENT ADDRESS C ,\ CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) <br /> (City,State,Zip) � C�Setbacks <br /> PHONE PHONE ❑ Site Plan al from <br /> applicabJe-township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS �� <br /> O'Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpy.Naccessda:•.:co.dane.wi.us/) 12/Elevation of property <br /> PARENT PARCEL NUMBER: q • RRENTZ•NING: ACREAGE: p p y <br /> PARCEL <br /> UM E R �J V 0 ? . -I �� 34 5 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP:�n SE ION: - <br /> I tpy��rpSQ f R/a: ]Vi is 1/a'/a: N ❑ Drivew permits <br /> ADDRESS: 1 F� (state;county,town) <br /> 10 3 F-r b. RA JeroAc, �►S 5351 3 ❑ Sanita permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (pubito,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PR JECT D CRIPTION: <br /> ,!_,t�- �C,�� ��l h� -- ❑ Zoning nct <br /> 4 is project is a new building or structure. <br /> ❑ Permitt Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: No $GN .I- Z/N C( 1e PERMIT NUMBER: 01 RU al Addr SS <br /> t SEWER SEPTIC Y i (new/ ' t ng) <br /> 41--G-HT IN FEE NUMBER OF STORIES: (Not including basement) <br /> 93-1/4011, / ❑ Wetland/FI plain/ <br /> Shore di(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 /> ❑ Erosio ntrol permit <br /> 15 2.�\ + TOTAL SQUARE FOOTAGE: + (si S,disturbance, <br /> v\ J lJ filing/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> (52-0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ ♦ ♦ ♦ $ O O and available options. <br /> (Please round to nearest dollar) 3 ( C)o <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes UI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes lEINo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? XYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 21-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) ❑Yes 83 No ❑Don't know <br /> 7. Is this to correct a violation? 1 ❑Yes 4 No <br /> �_ APPLICATION MUST BE SIGNED <br /> 545-112 laioe> \ (Continue on Back) ♦ ♦ —► <br />