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VI t 5 d <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> X4 ) ,dd6l ❑Zoning StattP; <br /> OWNERA DRESS (Number,Street,City,State,Zip) Deed Restrl On; CSM <br /> gZ015 $f /4 /4/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .525- /17i ❑Site Plan dr w to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes imensions <br /> AGENT NAME �,,� CONTRACTOR NAME <br /> AGENT ADDRESS s,, r(6V2 CONTRACTOR ADDRESS Zf�" ❑Site Plan ris dj�-location <br /> R ' ,&- X39 RS 12 23'/ I <br /> (City,State,Zip) (City,State,Zip) ❑Setb ks <br /> PHONE PHONE ❑Site croval from <br /> •- - .>��5—C appl' a to nship. <br /> E-MAI L ADDRESS E-MAIL ADDRESS / : <br /> C ii rV C2p/GCP-L,_. 4 ' 4 & a /• Carte_ ❑Floor plans tvCale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane:wi.us/) ❑Elevation o pr erty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL BER i''/.6 _ 25,2.9Z��,—D frontage dr to scale. <br /> NUM <br /> TOWNSHIP: SECTION: <br /> Pit-OI I .12/J %: co %Y4: ❑Drivewa pe its <br /> ADDRESS: (state,co ,town) <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF:`REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning DI t ct 'S <br /> ❑This project is a new building or structure. ❑ Permitter <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PEryilIT NUMBER: ! <br /> ® Rural Address <br /> EWER �EPTIC l ,t/1 1 <br /> V 5� (new/ex ) <br /> HEIGHT IN FEET: NUMBE SITORIES. Noot including sement) <br /> ❑ Wei ,,• to •• ► t <br /> AREA TO NEAREST SQUARE FOOT: Sh_•r f0"--:' ��,�� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ EroslonControl per It - <br /> 4, TOTAL SQUARE FOOTAGE: 4, CSIOpes,diStur e - <br /> filling7acces) <br /> 2ND FLOOR: 3RD FLOOR !— f r r ; .}- <br /> (� -❑ Revlew o urve <br /> ESTIMATED CONSTRUCTION COST: y <br /> ♦ ♦ ♦ -► ♦ ♦ S��5D•. and av I •:dons <br /> (Please round to nearest dollar) <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? Lives ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dyes Elo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Jlo <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 alo ['Don't know <br /> 7. Is this to correct a violation? Des [lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► ■ -* <br /> 545-112(4108) <br />