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. -n�-P . ►< 2 1vvti p i I vvi 1 r-e�,v�,ir�/ <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> - PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> be U t hnr\ 4- 111 a 6°1-11 <br /> oning Status;CUP; <br /> OWNER ADDRESS umber,Street, ty,state,zip Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> a �,/ <br /> y j OS� C Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions af2„V• ., <br /> AGENT NAME C TRACTOR NAME <br /> �J�,�, �, � <br /> "•J l' to Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (Girt?t , ip) Setbacks <br /> PHONE PHON Plan approval from <br /> 3 el- 3 Li I LJ 111 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ion of property <br /> ❑ PARCEL t l' (`t 106 `0 -b1 ,_qC _5 ■ rontage drawn to scale. <br /> NUMBER <br /> 1"C n <br /> TOWNSHIP: SECTIO : <br /> RJLL ri e. 1 1/a: 1"E '/at/a: SE ay permits <br /> ADDRESS: ( ate,county,town) <br /> 4 SO% Back-cam Rd t to w v- o 4- ()AKA-- Ke <br /> Iiii <br /> CSM: LOT SUBDIVISION BLOCK/LOT y permits <br /> 4anitar <br /> ubl ic,private) <br /> PROPOSED PROJECT INFORMATION S AFF REVIEW <br /> PROJ CT DESCRIPTION: <br /> C V oning District <br /> ❑This project is a new building or structure. <br /> rmitted Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SA ITARY SERVICE: PERMIT NUMBER: ❑ Rural A•R•1.- <br /> ❑SEWER SEPTIC (new/=r ist • • i � <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) r <br /> r <br /> ❑ Wetlan i •0•,•lain/ ., <br /> a Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> C!,em. ionuontr tpe it <br /> BASEMENT 1ST FLOOR: �� 1 TOTAL SQUARE FOOTAGE: 4. (slopes,distu1 nce, <br /> 2ND FLOOR: 3RD FLOOR: <br /> ♦ fillip cress) <br /> eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ to 00 O O 0 and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? .gYes ❑No R Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 4Yes ❑No 0 •on't know <br /> 3. Have you talked with the township about your project and are they in agreement? O• es ❑No <br /> 4. Has there been a zoning permit issued'for this property in the past 5 years? '=4 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) ❑Yes o ❑Don't know <br /> 7. Is this to correct-a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ —► —► <br />