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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 V 1'(t ) Wt1'A T ff ❑Zoning Status;CUP; <br /> ADDR SS u b Street,City,State, Deed Restriction; CSM <br /> qv di L(N ` k_1 C 5 TO(.(, kriek ! 'T3 ra, Variance(# ) <br /> HO E PHONE CELL PHONE 'E-MAIL ADDRESS <br /> i ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO TRACTOR NAME <br /> 6 uersi ok.'le ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A R F S S of well/septic <br /> -75 7 C r/e c Lh <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> -Cfbu�h.A� 5-n <br /> -AT PHO � II Site Plan approval from <br /> J/3-- //.5-9' 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: CURRENT ONIN ACREAGE: <br /> ❑PARCEL 0(0/d a 6 ZgOo0,3 f 5-0 •3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTIOli <br /> f\n Z '/a: '/a'/a: ❑Driveway permits <br /> ADDRESS:, (state,county,town) <br /> 33 IN 4 im ( ❑Sanitary permits <br /> CSM: /LOT SUBDIVISION BLOCK/LOT <br /> S (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIO j: , <br /> !//�,�f/�-�V;Pe 02-C k___ Cl 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 /> a EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: �( NUMBER OF STORIES: (Not including basement) <br /> ' ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1STF O ❑ ErosionControl permit <br /> 1 � <br /> 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3R1�FLOOR: `�'� filling/access) <br /> 1) �> • U�� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �� v 0 and available options. <br /> (Please round to nearest dollar) t O V <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 [lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 1=11(c <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 4a'"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) ❑Yes ❑Don't know <br /> 7. Is this to correct a violation? [Yes Ul(o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ .4 <br /> 545-112(4/08) <br />