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SUPPLEMENT to web App#ZONING PERMIT APPLICATION www.countyofdane.com <br /> `pRDPERTYOWNER:INFORMATION -. : . ":A, ° gis`R. CU OMER TO PROVIDE <br /> OWIaIERWRMAM <br /> j or f ,-lic i� <br /> OWNER ADDRESS (Number,Street,City,St e,zp) Zoning Status; CUP; <br /> 2?6 /—/AVER v i i It /) /� D d Restriction;CSM <br /> / �c!�' yAilia V fiance(# ) <br /> HOME PHONE LyP23F,�e-ryr EtreRE 6 t/ (/Y d //\)lr'�` si i Plan drawn to scale <br /> •AGENTINFORMAT - .'CONTRACTOR;INFORMATI�N; ,;t_ f, a includes dimensions <br /> AGENT NAME CO �CTOR NAME <br /> /��'i' ~ %I/e.- `,-sfi' ❑ to Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> S4-' 4S /4,Gv1 <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ ite Plan royal from <br /> a lic a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS • <br /> loor plans to scale <br /> PROPERTY/L'OCATION INFORMATION ' titt J/aceessdane co-dane_wr u_s "ter°' <br /> PARENT PARCEL NUMBER: CURRENT Z ING: ACREAGE Elevation of prope <br /> ❑NUMBER os/1- acp 4/ .1 , .6 0 i-a(y , .. frontage drawn scale. <br /> TOWNSHIP: S N: <br /> WNSHiP ,A.k 4:,7��,5 IA.:Svipil I I Drivew ermits <br /> 461 p (stat ,county own) <br /> ADDRESS:3 en /rAA,64 t';iti 1Q t J <br /> CSM: LOT SUBDIVISION BLOCK/LOT E]Sanita• permits <br /> 1��/� f 1 (•u• c,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> - i J <br /> PROJECT DES RI$TION: <br /> �D/ .5.77/4 D y CO �( + m oning District r -` <br /> [IThis project is a new building or structure. �r <br /> � Permuted ' ? -: <br /> ❑This project is an addition alteration to an existing building or stru tur . e ' <br /> SANITARY SERVICE: PERMIT NUMBER: / ® Rural .df2SS °t ~ <br /> EWER PTIC `y (new/e sting - <br /> 4 <br /> HEIGHT IN FEET: ,1 NUMBER OF STORIES: (Not indu ing basment) t s : <br /> _„4— / 1 :0 Wetlan /F Oraii1 n/ <br /> Shovel d{attachment) <br /> AREA TO NEAREST SQUARE FOOT: : �n ,=- <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR ,0 EfOSIOnCsonttro ! 411 <br /> k 4, TOTAL SQUARE FOOTAGE: 4, ```�(�SIOpeS,di rbance <br /> 2ND FLOOR 3RD FLOOR 7\ 1z s fill) glace _ssY # <br /> � _D Revl wLL}ocafior�Survey \\V <br /> ESTIMATED CONSTRUCTION COST 2s pjp v and availabie optjon-p <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ "� ST,, , <br /> - 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies I No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes to ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? jYes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - ®Yes ❑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 o ❑Don't know <br /> 7. Is this to correct a violation? :Yes to <br /> "i] C>) n 11(3 APPLICATION MUST BE SIGNED <br /> 545-112(4/D8) 7 (Continue on Back) -4 -4 <br />