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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME • AT, 1 e K. fit Od-O riltic ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number.Street,City,State,n ) cue- Deed Restriction;CSM i}L1 CE Zip) %ic O C v,Gv ...).3..)-7s° <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> bog-IN _Ida o 47116-EZO 5r761v6w/!64 17°7M4/4,Cam❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and Includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> •51-41? £)7(1C/2&-"'!L'`' ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (Gay,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/) <br /> El of property <br /> ❑ <br /> PARENT PARCEL I O NUMBER:©1C'O g1 CURRENT 20 ZONING: ACREAGE: / / frontage drawn to scale. <br /> TOWNSHIP: SECTION: 8G (0(0 <br /> 0iJ/1)41 1/.: 1/.'/.: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> Poi A-4-1CC p��,,v r PR DX 'iri -% 53:� 7S <br /> CSM: LOT r SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> t( l M 014 K ui0,1 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF RIVI p <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . Elms project is a new building or structure. 0 Permitted use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER PEPTIC (new/esi ) <br /> HEIGHT IN FEET <br /> 13 f NUMBER OF STIES: (Not including basement) ❑ Wet III1dIFloodplein/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE"'FnT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErO siO�I�OM101 permit <br /> BASEMENT: 1ST FLOOR:iv VA/ GX(rj'f/WL TOTAL SQUARE FOOTAGE: + (slopes.disturbance, <br /> 17 i 6o -t 17 C� filling/acs) <br /> 2ND FLOOR: 3RD FLOOR: �/ <br /> -!D6 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ -► $1[- and avail options. <br /> (Please round to nearest dollar) J <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 a o [Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes P� o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes tNo <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) Wes o ']Don't know <br /> 7. Is this to correct a violation? ❑Yes ao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -♦ <br /> 545-112(4/08) <br /> 8 o • 1c <br />