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4 06 . L—FO <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> OA i 0 t e/ ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> d Deed Restriction;CSM <br /> 1(0 2 57' Rd • 11 6414 I0r,+i r c G Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 77— 91 O b #e < ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5•41■ a S. . ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE n 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.whusn ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL G $i o 01(-'097 o A 9 frontage drawn to scale. <br /> NUMBER ' ' 7 <br /> TOWNSHIP: SECTION: <br /> • y�i� %4: '/a'/a: ❑Driveway permits <br /> �K <br /> ADDRESS: (state,county,town <br /> ‘7.5-4 'a St. id . 1, SN A ' PrO Y.e. ❑Sanitary permits <br /> CSM: LOT �+ SUBDIVISION BLOCK/LOT (public,private) <br /> J <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> •■/).q .1 ❑ Zoning District <br /> . <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 XEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> Avg. i t <br /> ❑ 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 /> 472 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 47a <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: r b and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ --I. ♦ $ a'ODs, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? NYes Llo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? kfres alo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? : , yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes IgNo <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 al. ['Don't know <br /> 7. Is this to correct a violation? ❑Yes plo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -0 -► <br /> 545-112(4/08) <br />