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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 01/ply NAME n,, <br /> Y " ' S [r Zoning Status; CUP; <br /> O RADD ESS (Number Street,City,State Zip) <br /> / f ' / Deed Restriction; CSM V I Q V�L� �i t j Variance(# ) <br /> H ME PHONE CELL PHONE t� E-MAIL ADDRESS I -7 ` <br /> IL i5'3�y 1 . -.. Dt-� (0 GA'1�■1. ErSite Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME____)E f. '/ E i <br /> ( o F-^, cs (0 0); -}me) 1✓ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDR Eiss of well/septic <br /> g3c\ �A f <br /> (City,State,Zip) City,State,Z ) Ei Setbacks <br /> Dee 33' s <br /> PHONE PHONE [v]�Site Plan approval from <br /> QC° !_.L 21/43a0 applicable township. <br /> E-MAIL ADDRESS E-MAIL AiDDRESS <br /> 01 U S . iNJ1J---? / n - loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p Elevation of property <br /> nPARCEL frontage drawn to scale. <br /> 'NUMBER <br /> TOWNSHIP: SECTION: <br /> IA: %4'/4: Fl Driveway permits <br /> ADDRESS: (state, county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> dQ `cc3Ac A Al 0 Zoning District <br /> . This project is a new building or structure' <br /> 0 Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rural Address <br /> rEwER FIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Q 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: Q ErosionControl permit <br /> 12-170 + TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> a Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) d` Z ( � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? nYes to nDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes EK nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dies ,__,/Itlo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies o <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) Ffres 17No DDon't know <br /> 7. Is this to correct a violation? Dyes DNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —t. -* <br /> 545-112(4/08) <br />