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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN" i E •., <br /> J1) 1iei fA9Ni(! <br /> n Zoning Status; CUP; <br /> O AtTS r4 umber,Stre Vity, -te Zip) I r a ,� 1n S I ,�?, Deed Restriction; CSM <br /> 761 j iM& Mt "�'"9 ! �"'` 1 ✓�j1 Variance(# ) <br /> HOME PHONE ELL',HOVE/� E-MAIL ADD ESS <br /> /Cnit 4 rC..I 1v14-4-) -cow) • n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME 1 , TRACTOR NAM n I <br /> ( Ciethjr Ze .U/ die?. n Site Plan including location <br /> AGENT ADDRESS CON ORES <br /> of well/septic <br /> V I fylit Ifyi <br /> (City,State,Zip) (CA Vate,Zip) n Setbacks <br /> I Ve Nip J,1i'(D WI 53c11 <br /> PHONE P ONES 6� m �1 ❑Site Plan approval from <br /> �(� / /' applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> m )G l'j,/, , 121" i.Gi(5 .tar\ n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc.essdane.co.dane.wi.usn Elevation of property <br /> PARENT PARCEL NUMBE : CURREN ONING: ACREAGE P p y <br /> I '14 NUMBER <br /> (/lo� 1 115 0 1 �- �' frontage drawn to scale. <br /> TO HIP: qq�n SECTION: <br /> �� I� bd �i Y4: ,/4,Y4: n Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> /DG /4 y1 to /4.)-e_e--. <br /> c �� LOT J SUBDIVISION BLOCK/LOT n Sanitary permits <br /> I (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE DES IPTION: <br /> D ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER , EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER)OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT' 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> I 1 �l /�/J}if� 4I CV j TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> L�(�'�1t filling/access) <br /> 2ND FLOOR: 3RD FLOOR: c Ito 7 <br /> IYa ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 65 p Ov v and available options. <br /> (Please round to nearest dollar) U <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes nNo (Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Is es nNo (Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? MI es nNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? I JYes - No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# (Nil/ ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) /es nNo Don't know <br /> 7. Is this to correct a violation? [Yes }�(RJo <br /> 2U \b - 03�a !� <br /> 7 1r/ APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► -* <br /> S45-112(4/08) <br />