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bCPzje - z ,6 --0oSS-7 0 <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www-countyofdane.com <br /> PROPERTY D�OWNER INFORMATION CUSTOMER TO PROVIDE <br /> o�N//�UV'�e �/0 i �!'j CA pt��1�� ❑Zoning Status;CUP; <br /> O ER ADDRESS (Number,Street,City,SStat ,Zip) ✓" '�",JJ / �j .,3 Deed Restriction;CSM <br /> HOM�PHONE (44-CJ L PHONE C�E-MAIL ADDRESS <br /> Ai/ cS Variance(# ) <br /> e•-'71 , W..4/03( A Oe ' t' MO)r-AL0 ❑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 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 ZONING: ACREAGE: <br /> ❑ �/ r I' z77 frontage drawn to scale. <br /> NUMBER ox/dlo7--173-711 -0 kAl :k r + <br /> TOWNSHIP: SEC ION: <br /> e6 PL-/�( /7 1/4: - G o '/4'/4: I. ❑Driveway permits <br /> ADDRESS: u / 067" (state,county,town) <br /> le p 1✓- G- �z A teP <br /> ❑Sanitary permits <br /> CSM: 13 C93 LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO ECT DESCRIPTION: <br /> App Go R./ 61- Ll(,•1 A6-/ 7--241 2z) ix '17,v Oil f ❑ 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 /> 2 d r - ❑ 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 /> P 2 C704 4, TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, <br /> 2ND FLOOR: <br /> (.2 C/, 3RD FLOOR: S 50 filling/access) <br /> SV <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: _o. .4 ..+ ' <br /> / and available options. <br /> (Please round to nearest dollar) ♦ ♦ ..+ $ C 1 (jd� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [ Yes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeslo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ❑No <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) [✓7'es ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes [v io <br /> ! tt re:— ' <br /> r+ APPLICATION MUST BE SIGNED <br /> ,a �- ? v (Continue on Back) —► —► <br /> 545-112(4/08) /,e1 0 I. <br />