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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OWNER NAME <br /> ark n Aoili I_ Zo mg Status;CUP; <br /> OWNER ADDRESS (Number, r et,City State,Zip) D ed Restriction; CSM <br /> $° l 1 c\ A Q(' 01-) WI S36'7.5" ariance(# ) <br /> HOME PHONE ( CELL PHONNEC� E-MAIL ADDRESS 1 <br /> ,O:4 5/3a`�-1 p 73g 4.. IO /M" lefiniAl ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION a/ad includes dimensions <br /> AGENT NAME CONTACTOR NAME , <br /> Sion 1) ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS <br /> Q 1/ ;of well/septic <br /> 143091 MIA Ave) <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> t 11r0C W 1 53566 <br /> PHONE PHONE / ❑S. a Plan approval from <br /> 6(13 F 3�5 '4000 pplic Itilownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS i // <br /> Flo r plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) evation of property,. <br /> PARENT PARCEL NUM ER: Q�l� CURRENT ZO1- 'e1 G: ACREAGE: evation . <br /> ❑PARCEL O So 9-A 3/ (IV-6 Al 1 C 30& 6 frontage drawn to,sale. <br /> .7 ,-' <br /> TOWNSHIP: CTI : `_ <br /> a ,1 '/4: 4,,.1'' '/4'/4. S ❑Driveway pe-rmits <br /> ADDRESS: <br /> ,E. (statounty,town) <br /> -SCOS 6 64 &t A ❑Sanitarypermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (• • 4 private) <br /> PROPOSED PROJECT INFORMATION I STAFF REVIEW <br /> PROJECT DESCRIPTION: Fre.e. S all krn 9 . J / k,/ Y <br /> ✓\ �( Ld C/� . -oning District <br /> . [NThis project is a new building or structure. ® Permitted e? <br /> ['This project is an addition/alteration to an existing building or structure. ,A SANITARY SERVICE: PERMIT NUMBER: h ❑ Rural A re ! <br /> EWER WEPTIC V (new/e 'sting) <br /> HEIGHT IN FEET ,f NUMBER OF STORIES: (No including basement) <br /> I G/1. ❑ Wetland/FI dplain/ <br /> Shorela (atta ent) <br /> AREA TO NEAREST SQUARE FOOT <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r--1 ErOSIOnC1Jt1Tr01 permit <br /> BASEMENT: 1ST FLOOR: / <br /> j 5 3 ,, TOTAL SQUARE FOOTAGE: + (slope ,disturbance, <br /> I ! ' filli access) <br /> 2ND FLOOR: 3RD FLOOR: I�j 3^� <br /> "I ❑ Review Location Survey/]/A\ <br /> ESTIMATED CONSTRUCTION COST: $ "� ('� 0/� and •available options. v v1 U <br /> (Please round to nearest dollar) ♦ "'� "� -� ♦ ♦ $ �1� Yj lk-i <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? Efres EINo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Wes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des ' 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 Jlo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —0. —0 <br /> 545-112(4/08) <br />