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Z � ' � <br /> lqc 2 (C�q �-"' ` SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> J a"`e S e e.-- honing Status; CUP; <br /> OWNER ADDRESS (Number, reet,City,State,zip) �r / L/ Deed Restriction; CSM <br /> /5 �`of, �,� �� er7o,� CJ� 53 5 S/ Variance(# ) <br /> HOME PHONE CELL PHONE // 1,, E-MAILADD�,ESS ` <br /> `��- si V-6.20 5 Y.-289-37J7 J ' 8ee-,r 6•.-F Ct L - 1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME COf ffRAATOR NAME „.r ��/ <br /> J , /J e ci 'v C,,s A. ,an c 'C� Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5-6,,,,x_ 6-5 6-'" <-- ,�, <br /> (City,State,Zip) (City,State,Zip) l!1'Setbacks <br /> PHONE PHONE qilte—Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ZONING: AC AGE: Ievation of property <br /> 0 PARCEL )D)-, 15/02 _]91_,� _(: 1 frontage drawn to scale. <br /> NUMBER `� <br /> TOW�+�HIP: SECTION:/ 00 <br /> , 1410C l (.vv1st 0 5 3 tit Ya: '/4'/4: kvii P nveway permits <br /> ADDRESS: <br /> / state, <br /> J s 3 ,state,county,town) <br /> S Ter �� G/� ,� ` 3 5 / <br /> CSM: LOT SUBLDIVISUON n BLOCK/LOT '��' ,anitary permits <br /> cc( no / (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> 11 e h X71-h-(.(,� 1i0 Zoning District <br /> Q his project is a new building r�cture. <br /> P J 9 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: 126;TIC NUMBER: Q Rural Addr- <br /> ❑SEWER is SEPTIC (new - sting - v� /// <br /> HEIGHT IN FEET: /7 / NUMBER OF STORIES: (Not including basement) \'s ET <br /> (/ A Wetland o lain/ Of <br /> AREA TO NEAREST SQUARE FOOT: Shoreiand (attachment) t <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: sionConi permit <br /> 4, TOTAL SQUARE FOOTAGE: 4 (SiOo- ' ' "°'`. ° <br /> . tnglaccess) <br /> 2ND FLOOR: 3RD FLOOR: #3)-00 �,�'- <br /> S y ►_I Revtew Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ? and available tflptiOns. <br /> (Please round to nearest dollar) ' / OQ 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 21 Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? �❑.Yes UN- ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Yeses ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 0 Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank ifnone) <br /> 6. Is a location survey required? (see reverse) ❑Yes ,e-. loo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ai <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -1 -0. -* <br />