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SUPPLEMENTao;w.eb App°#'' <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION ,_3 CUSTOMER TO PROVIDE <br /> WNER NAME `�Q c� (N <br /> V (e " '�- J <br /> . : ❑Zoning Status;CUP; <br /> O DRESS (Number,Street,City,State,Zip)�(_ �4 Deed Restriction;CSM <br /> C\ ��rNek_"r `v\ - '— \ t•t -) Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 8 —12--5 ❑Site Plan drawn to scale <br /> AGENT INFORMATION -: CONTRACTOR INFORMATION'`°D ;, . and includes dimensions• <br /> AGENT NAME C Tv1T R NAME .-V5 1\4 Cam <br /> - _ ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A Rq Ess �( of well/septic <br /> (City,State,Zip) (C ,State,Zip) �� J �,� ❑Setbacks <br /> S--COUC ‘\-. W c 53S`P' <br /> PHONE PHO J ❑Site Plan approval from <br /> l`5.1 applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS •• <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http6l/accessd00e coda_ ne wLuse t 4g-M: ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT NINE ACREAGE: <br /> ❑PARCEL 06n' Z4 Z2Uoa) L > p frontage drawn to scale. <br /> NUMBER � I Yj <br /> TOWNSHIP: SE T1O : <br /> 1/1_11A , //4. ❑Driveway permits <br /> 4. <br /> (state,county,town) <br /> ADDRESS: <br /> CSM: b' 5 / LOT 4/ . _ -1 suBDm` sloI BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION R W <br /> - <br /> STAFF EVIE <br /> PROJECT DESCRIPTION: `' 111 <br /> if n (1, 40 ivv-e____ 1_1'!.Zo'hi.fig-Pistrict r <br /> his project o'ect is a new building or structure. err t ` 3 '3 z <br /> La P 1 9 ? ;i, <br /> � Permltfed Use _. <br /> ❑This project is n addition/alteration to an existing building or structure. <br /> MA * �F r <br /> j a <br /> i ms s X ii,; <br /> SANITARY SERVIC PERMIT NUMBER: „------- ® R ual Addres t_f . <br /> EWER PEPTIC > 4(new/exlsting) TS- <br /> x <br /> HEIGHT IN FEET: I ( �� NUMBER OF STORIES: (Not including basement) x . rr-rr <br /> ,0 Wetland/F000dplaln/ <br /> Shoreland{attachment) •. <br /> AREA TO NEAREST SQUARE FOO . r., � <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) -�` - ,F <br /> 0 EroslonControl permit' <br /> BASEMENT: 1ST FLOORO 4,TOTAL SQUARE FOOTAGE: I, �SIOpeSJf4I5tU nce� <br /> 1, filfing7accessY i <br /> 2ND FLOOR: 3RD FLOOR // ) ., i, tt { r <br /> t I OVIewLLocatlop SU"rvey <br /> ESTIMATED CONSTRUCTION COST: .;i7:1 -and v allabe optonfl' <br /> -10- ♦ ♦ -10. ♦ "+ a �� O> O O � l <br /> .r <br /> :(Please round to nearest dollar) ,z-5_{ X-s 4u a :i ,I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? • 'ales LINO ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes J"v ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? :Yes ENO <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - [Yes ❑IVo <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) Ekes ao ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 12tcro <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -► <br /> 545-112(4108) <br />