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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 /> NCO le / O'eft&A ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> t15-5/Z L,DZ{-v5 Ln (,) 5-3 z Deed Variance Restriction; CSM <br /> � � � �'�—JJ � Jr 7 Variance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> '6D$—ZZS--I5-Z$ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONT-'CTOR NAME <br /> ` (Ows4('c4i -. LL.£ ❑ Site Plan including location <br /> AGENT ADDRESS CONT'•CTOt ADDRESS of well/septic <br /> ro X 1-/(351 <br /> (City,State,Zip) (City State,Zip) , Setbacks <br /> Uil e.( ,WI .-35-3/ <br /> PHONE PHONE 1 ❑ Site Plan approval from <br /> 60'-6 _Z 97 z applicable township. <br /> E-MAIL ADDRESS E-MAIL•'DDRESS <br /> Pe 'h,f Co n If Y"o6 < Lp14-• LI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 1 frontage drawn to scale. <br /> NUMBER <br /> TOWNS SECTION: <br /> '/a: '/a'/e: ❑ Driveway permits <br /> ADDRESS I (state,county,town) <br /> bbl Lf LAS '' -vt ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: II <br /> MO") 51n$I Vi d7 ham ❑ Zoning District <br /> ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: XSEPTIC PERMITNUMBER: ❑ Rural Address <br /> ❑SEWER (new/existing) <br /> HEIGHT IN FEET / 2 NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached gara es and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: / , Eropes,di ntrol permit <br /> 9), 7/F/T)��Ip J 1/( o TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR. filling/access) <br /> 2_7m-75---25 <br /> �� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ ) ) O and available 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 ❑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 pro ect and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this pr perry in the past 5 years? ❑Yes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICA ION MUST BE SIGNED <br /> sasttz taroe> 2 Vt e 0 (Continu on Back) -+ ■ -► <br />