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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVI <br /> OWNER NAM / _�� <br /> C�'/7Gf f7D it,Sm1/ i Zoning Status; CUP; I / <br /> OWNERDRE S (Num r,Street.City,State,Zip) Deed Restriction; CSM ) -z j/ f5 <br /> ? ,5'( O21dct/ n /n D �r,(y' -.c 41/53547 V. •- l <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> to 0 g 22,2-3Y(:, (P i- - . 2)-,g i4 a 4'u,s'u f*i (2 't9/ Cam ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION an Inc u es r• <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS a wAU1septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks /L./ /+ ° % tr <br /> PHONE PHONE Site Plan approval from Si C <br /> applicable township. <br /> NA_ <br /> E-MAIL ADDRESS IL Floor plans to scat��,F/_ / f l (16 1 f <br /> ..ate• <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ( Elevation of property / <br /> PARENT PARCEL NUMBER: - CURRENT ZONING: ACREAGE: p P rty <br /> j PARCEL 9 7 1/_(�S [�_32' ; frontage drawn to scale. <br /> NUMBER l•� // <br /> TOWNSHIP: SEC ONr / { <br /> C U '�.I- �Q / 5 1/4: S W '/4'/a: .s. I� , Driveway permits i 4,_ <br /> ADDRESS: (state, county,town)'" <br /> 2 7 S/ <br /> CSM: LOT sue.VISION p BLOC OT ^ Sanitary permits A, <br /> / 6e 6-3- (public,private) <br /> 6 3 an Ca,/ei:,wi.,, —/S, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: f\ II L <br /> J �•t Zy �T `r 51,-e_c District np- <br /> . <br /> This project is a new building or structure. 94 Permitted Use?rJ e.4_ f e3 S�t' <br /> ❑This project is an addition/alteration to an existing building or structure. �{ r S�C,� <br /> SANITARY SERVICE: PERMIT NUMBER: iv/A... ,�J Rural Address <br /> ❑SEWER SEPTIC **Rural <br /> (new/:•isttng <br /> HEIGHT IN FEET: �� \ NUMBER OF STORIES: (Not including basement) / <br /> .. / ;24 Wetland/Floodplain/ J <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment/ <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) / <br /> BASEMENT: 1ST FLOOR: EfOSIOr1COntrOl permit ,� / <br /> A0 + TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, /�// <br /> 2ND FLOOR: 3RD FLOOR: / lJ 0 filling/access) <br /> eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ Q� ��� C nd available options. <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? ❑Yes a-■o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Li Yes iE1No ❑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? Li Yes ❑No- i'19 d-'- A-s4'2') <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 (bon't know <br /> 7. Is this to correct a violation? ❑Yes -No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ♦ —o. <br /> 545-112(4ro8) <br /> A <br />