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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> / <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> bkV 1 p LaSkCc i s\ -;I I;+rDO „,2._ Gtro S I -0 <br /> OWNER ADDRESS (Number.Street,City,State,Zip) — ODeed g Status; CUP: <br /> 270 OUJ LlAr'J i] 12- L'(JtWIP�etiI(e- W t �- SZ3 Deed Restriction;CSM <br /> Varence(# ) <br /> HOME PHONE CELL PHONE MAIL ADDRESS <br /> 70, q0 3. 7761 l •Ircr,L.0 e a y(,ta,,;I, L O WI Ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and ludes dimensions <br /> AGENT NAME CONTRACTOR NAME / <br /> iAc'V-- 1402-1—e2--� ht e0inc 41 K 131/ t4e-- (Site Plan including location <br /> AGENT ADDRESS CONTRACTOR AD R� of well/septic <br /> wla2,8� t;ba�� �� W1a393 Q0 <br /> Ia ,State,Zip) <br /> ( (City ty Zip) <br /> Setbacks <br /> troac nr�A I W t 5� _j 8 �2-ril"l/i�(n v, �� J 3J 32 ❑ r <br /> l. <br /> PHONE PHONE Site Plan appro al from <br /> om <br /> Au). (v s0 , 4.(A b(9; ,4 A 4 pplicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / <br /> hatr4W t 'W16U I• Conn c(o. lAac-k.r@ • A ku—. Co IM floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) / <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Li Elevation of property <br /> PARCEL <br /> NUMBER O I�a�O(�12-363_s S06 '9 >4--( (Ex) \ Z(7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: ,7,-‘,`) - -' <br /> :.tie-tSjtA/QA- 3(p ,/Wit_ '/,'/:_� v ❑Drivewaypits <br /> ADDRESS: (state,�otnty ) <br /> 270 0 L�j LCA t\i lam• Cawi b t 644''/ W I `:j--3 Z' Sanita> rmits) <br /> CSM: LOT SUBDIVISION 1 8 Oi CKILOT <br /> (pbblic,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION � <br /> ;2_',;.;6, u(ic�I iao 4 1 A moil C/ a� tol 1 poc-k g Zoning District <br /> ❑This project is a new building or structure. <br /> Us-Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER: ❑ Rural Address <br /> A 110-- <br /> EWER REPTIC (new/ex sting) <br /> HEIGHT IN FEET: i ,/ NUMBER OF STORIES: (Not including basement) --- <br /> 7j j Li Wetland/Ftoodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: -- — ❑ ErosionControl permit <br /> 432- 4 TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: —" filling/access) <br /> ❑ Review Location Survey C <br /> ESTIMATED CONSTRUCTION COST: and availab,e options. <br /> (Please round to nearest dollar) —r ♦ —* '•• "► $ ;Z 1 000,0 Q <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 ElNo ©Don't know <br /> 3. Have you talked with the township about your project and are they ii;agreement'?- Eyes r]No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eves jNo <br /> 5. Is this project associated with a rezone/CUP/variance(netitton/appeal 4 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) r]1'es fNo [Don't know <br /> 7. Is this to correct a violation? Eves ®No <br /> APPLICATION MUST BE SIGNED <br /> sas,tz taros) � 8c) , fA (Continue on Back) � � —► <br />