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SUPPLEMENT to Web•App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVI <br /> OWNER NAM- <br /> C^ ,, L CO L 4- y oning Status;CUP; J� �! <br /> OWNER ADDRESS__ _, 6 ,, e <br /> (Number,street,City,State,Zip) Deed Restriction;CSM /c /1 <br /> HOM/P0 PHONE L K C LPHONE 1�J E-MAIL+ D IRISS Variance(# )C t4 e <br /> (al Site Plan drawn to scale <br /> AGENT INFORMATION • CONTRACTOR INFORMATION and includes dimensions 1C <br /> AGENT NAME CONTRACTOR NAME p <br /> 4'7( L.t t1 �3-126-f-Di��o, Site Plan including location k <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> •z4- (7(■ 1`' 6'/D '� 3/ /o�' <br /> (City,State,Zip) (City,State,Zip) Setbacks / <br /> PHONE PHONE ( Site Plan approval from <br /> Zet _ 0�J 7>Q - applicable township. //� <br /> E-MAIL ADDRESS E-MAIL ADDRESS • <br /> Dom. cEc 61-0 j _ ■ ,"Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.WLUS4 �, Elevation of property /4 <br /> PARENT PARCEL NUMBER: CURR T NING:) ACREAGE: • frontage drawn to scale 0 DNUM ER '(9dg( (�/�1 L - I 34/ , <br /> TOWNSHIP: SEC p�} <br /> d VIP G F VAR )la- 7`� '/4: N fa%a: �� Driveway permits <br /> ADDRESS: (state,county,town) <br /> �( 3 hi a f f , Grove [LO 6 4 <br /> CSM: LOT SUBDIVISION BLOCK/LOT (Sanitary permits <br /> � <br /> __. (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF:;REVIEW <br /> PROD�T° CIQIP 10 / / , r <br /> / �� I �. E'✓ 6c ?O. r3 Jo Zoning District e.'"'(ti, 43 <br /> This project is a new building or structure. ACPermltted se, <br /> This project is an addition/alteration to an existing building or structure. -,j -- , �C <br /> SANITARY SERVICE: PERMIT NUMBER: L -R Address 2 <br /> EWER EPTIC existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (No including basement) <br /> 7 J Wetland/Floodplain/ <br /> / Shoreland`(attaCl ment) ; <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ▪❑ EroslonCOntrol permit <br /> / 4, TOTAL SQUARE FOOTAGE: 4, �SIOpeS,disturbance - <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: / , I • F <br /> / 7 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �( / and avallabie o`dons <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ �U ��� c` p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes DNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes Digo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes lalo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dyes DNo <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) Dyes DNo DDon't know <br /> 7. Is this to correct a violation? Dyes Dpo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -1 -0 -0 <br /> 545-112(4/08) <br />