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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER`NAME <br /> pf d ` r1`,jsv e �x-h1\11 ❑ Zoning Status; CUP; <br /> OWNER AD ESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> A o btla Read i OVA t1 031 4a53-13 Variance(# _) <br /> - ONE CELL PHONE E-MAILADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONT CT NAME <br /> Fliff\Q CLD __7 c UV1da 1c <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS _{ of well/septic <br /> t4010 E - r1.Ji/av\ ��Q. ❑ Setbacks <br /> (City,State,Zip) (City,State,Zip) c� -7 <br /> 1iu MoUI S) l.Ui 5 i ! ❑ Site Plana royal from <br /> PHONE PHONE pp <br /> (s0a- 1-131_ulg) applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> U C , lk'. L' Ib r . IA . ' ,C64"1 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: I-r-pri ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER 04a\OSG9-%U1-1-(1)31�'L5 R .1. o <br /> TOWNSHIP: SECTION: <br /> OC O` _S E __ v:__ - ����' __ ❑ Driveway permits <br /> `' — - (state,county,town) <br /> ADDRE <br /> 1 'kla ZaC� OC c' �1 75 ❑ Sanitary ermits <br /> CSM: LOT t SUBDIVISION BLOCK/LOT <br /> (public, private) V\ \o_, <br /> ■1 ■ - e <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> nda ril I- On ❑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: Li Rural Address <br /> 0 SEWER I:11 SEPTIC rAck, (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: ❑ ErosronControl,permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 51A. frying/access) <br /> 2ND FLOOR: 3RD FLOOR: 123(P 1 <br /> $5 -725 '1 _ �� 1 ❑ R;view Location Altvey <br /> ESTIMATED CONSTRUCTION COST: and a options. <br /> (Please round to nearest dollar) - kUI we,.c available <br /> 4 143, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes y4o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ANo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 1.4 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes W'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 14 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes yiNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -► <br /> 545-112(4/08) <br />