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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 r <br /> 3O 0Zh 5 i LE ❑Zoning Status;CUP; <br /> ADDRE S (Number, reet,City,State,Zip) Deed Restriction;CSM <br /> 21150 -FA/R V Mu 5'1 5:1oo94,01i g WI 5358 9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> r7 / — — •,1 - I, 41 •G(' ❑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 ADDRES E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL pC.I1-i$3_41'2P_3 3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: 1 SECTION: <br /> 1/4: '/4'/4: ❑Driveway permits <br /> ADDR �a SPIN S (state,county,town) <br /> 497950 FAI ; yield ' 54011 I ❑Sanitary permits <br /> CSM: LO SUBDIIlion <br /> ON BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ` STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 1 lA7R3� Y10 ❑ Zoning District <br /> . This project is a new building or structure. <br /> Li Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER: ❑ Rural Address <br /> WER TEPTIC (new/existing) <br /> HEIGHT IN FEE : NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <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: ❑ ErosionControl permit <br /> SQ1i 4, TOTAL SQUARE FOOTAGE: ,,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/aCCeSS) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 1 OQ� 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 to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 26o ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ri'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I JI <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le ve blank if none) <br /> 6. Is a location survey required? (see reverse) es alo ❑Don't know <br /> 7. Is this to correct a violation? es ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) %.0 <br /> obi 1 <br />