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• <br /> SUPPLEMENT to Web•App# <br /> ' ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1.--144k y e 6 I Zoning Status;CUP; <br /> OWNER ADDRESS (Number, treet,City, tate Zip) Deed Restriction;CSM <br /> .N1 -4/Ai `�'l 4-.Ecpt ,i[ e.11 e J i & \IIS Sl so q Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ,(1— 3 78 6 3. • e .,g i. Ng Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> j l40 I gui(de(-S .`-t Site Plan including location <br /> A ..111: SS CONTRACTOR ADDRESS of well/septic <br /> hj377 Faiey 4( <br /> City,State,Zip) (City,State,Zip) A Setbacks <br /> gR l(tAri 1(e 58 Sob <br /> PHONE PHONE Site PI approval from <br /> -- ila Li-�!g 7 appli bletownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 4 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdane.co.dane.wi.us/) Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> Li NUMBER P-SCCi-c c+'(-c1S o / <br /> S —/ e J( ,... frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> or e.Sa n S /: S C //: S� Driveway rmits <br /> ADDRESS: (state, unty,town) <br /> �81a 4 aq 41 J) Or-ev»-1 WI 53x-75 <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanaa ermits <br /> (pub' ,private) <br /> - <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION. A L r p d d i <br /> }�(1 G 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 /> /1 (new/: `°, <br /> ❑SEWER SEPTIC Ni I <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 Wetlan•, loodplain/ <br /> j I 1 <br /> AREA TO NEAREST SQUARE FOOT: Shore =nd (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> Cif Erosion ntrol pern4 <br /> BASEMENT: 1ST FLOOR: 3 <br /> 6'-7).- , TOTAL SQUARE FOOTAGE: ,, (Slope ,disturbance, k <br /> 2ND FLOOR: 3RD FLOOR: O f llln cress) <br /> �--1 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ -► -► ♦ h <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes I No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 10 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? aYes ❑No <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 2 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 41 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />