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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION a ,... _4:11,- , CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> loa le t e/eff /ark a SSA", /A/C ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 4.?7. JoPIadi Di; e1-i' f4.(l47 w/ 53.5-Se Variance(# ) <br /> OME PHONE CELL PHONE E-MAIL ADDRESS <br /> , 3 -- # ‘1 -9/73 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR:INFORMATION::. ,, and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> / '11'- ' / /,/0 e / ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> `(1/f 3-afda ii or r . <br /> (City,State,Zip) (City,State,Zip) LI Setbacks <br /> )' 7C /Cs at/ad/J if)/ 37,773751 <br /> PHO / PHONE ❑ Site Plan approval from <br /> bQ t�r 1'3S_ 7I-6'S applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMPARCEL BER 620.00-17.1-11)1/- R- 4/ , frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> • A U/y A/ /7 .1/4: N 6) w : A/c ❑ Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PDROE OSSED�PROJECT INFORMATION <br /> ter/a6cc 7'10 to/1 ( to X /z ' ®�,, oLt t <br /> . XThis project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. � r ° ',A7= <br /> SANITARY SERVICE: PERMIT NUMBER: -F�»1°.6i,,F X�' •t'-'',;:' <br /> �❑SEWER ❑SEPTIC 4°� g , �u,- -x;, <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) of � <br /> AREA TO NEAREST SQUARE FOOT: '� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ,, � e ° ‘@ ,P.� 9 -" ,, <br /> a <br /> 77 c0 /02 b 4, TOTAL SQUARE FOOTAGE: j g'� � o- , <br /> 2ND FLOOR: 3RD FLOOR: . � 1 <br /> I - 0 <br /> ESTIMATED CONSTRUCTION COST: � , ,m I/ Q r @.... <br /> Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? yi Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 0 Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? , Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 0-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 ❑No ®Don't know <br /> 7. Is this to correct a violation? ❑Yes 5-9' APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► <br />