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.9(9 . L\ <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA I, �� <br /> '{, G�V1 ❑Zoning tatus. UP; <br /> OWNER ADD ESS Number,Street,City,State,Zip), Deed R tr. Ion; CSM <br /> � <br /> � 1 <br /> I-0 GV 51— ljf V.Q- Variance ) <br /> HOME PHONE CELL PHON E-MAIL ADDRESS <br /> 60 i 575 5 Q i 7(9 ❑Site Plan drawn cale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and include • ensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site PI n in ing location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/ is <br /> (City,State,Zip) (City,State,Zip) ❑Set1 <br /> PHONE PHONE ❑Site Plan pr <br /> applicab to hi <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor pla scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) ❑Elevation of pr erty <br /> PARENT PARCEL NUMBER: 2? �j1q CURRENT ZONING: AC AGgE: r <br /> ❑NUMBER 00./\J ^ JJ� {�,D_ / TF"I'— I 9 t� �Q frontage r ntoscale. <br /> TOWNSHIP: SECTION: <br /> v�YrG✓i 0 '/4:,6 0.,' <br /> 1/'/4:ALE ❑ Drive y er <br /> ADDRESS: (Staten ,t Wn) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑(pub ry <br /> (pub c, ri <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5 .1(110 S�5 iiQj W/ 0tech`Fort in ❑ Zoning . trict <br /> . This project is a new building or structure. I ❑ Perm d Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER (01k,TIC (new/eop) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> .c:Alt. <br /> ❑ Wetlan•/ to ,r• <br /> Shore!. • - a• ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions i ding unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErOS10nC t• • It <br /> • 7,2-4, TOTAL SQUARE FOOTAGE: 4, (slope d •ance, <br /> v filling cc s) <br /> 2ND FLOOR: 3RD FLOOR: r <br /> (g 7 ❑ Review oc ti,i rvey <br /> ESTIMATED CONSTRUCTION COST: and av -p •ns. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ $ �t{006 <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 ❑No ,[Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'ales OW <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes MNo <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 gi o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes allo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -i <br /> 545-112(4/08) <br />