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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 /> Ghar6s t{• �urrk �"' ❑ g <br /> Zonin Status;CUP; <br /> OWNER ADDRESS (Number,Street,Cit st e, Deed Restriction;CSM <br /> �6 g �dQ ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL A DRESS <br /> o�Ol�k% r .12 ; - - ; L.'S he+RwcNGkW k 4 ` Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NA CONTRACTOR NAME <br /> 54t vvvt E ['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/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: �y/ CURRENT XII ACREAGE: <br /> ❑NUMBER I'J.S7, —ZZ ` _oTio_ frontage drawn to scale. <br /> TOWNSHIP: i —SECTION: <br /> I <br /> R /�v4 'Z2 '/4: '/4'/4: ❑Driveway permits <br /> ADDRESS: p j� (state,county,town) <br /> 374 D p old 5' " ee. Rol ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> l a 0 i-Z___ (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Z If 7C.7 Z 5-.4 .,...11 ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPTIC , (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /it' 1 ❑ 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 FLO R: r--, ErosionControl permit <br /> �] <br /> 1/X 4, TOTAL SQUARE FOOTAGE: ,l, (slopes,disturb <br /> ance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ��� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �vv. -,�. and available options. <br /> (Please round to nearest dollar) -► ♦ ♦ ♦ ♦ --► V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes JNo ❑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? ®Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ONo <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) Dyes ❑No [Don't know <br /> 7. Is this to correct a violation? ❑Yes wo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► <br /> 545-112(4/08) <br />