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1 <br /> 1 <br /> SUPPLEMENT to Web-App# <br /> 'ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME f <br /> � tr I , i7 an ' n'ng Status; CUP; <br /> OWNER A (Number,Street,City,State,Zip) ed Restriction;CSM <br /> 73`/7 S P/'�n /t e/f /J/ 174x1 &2 S-3.)a 9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .0.-9 --966/ 608-%vy 735 ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION a • includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ∎1 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS .f well/septic <br /> (City,State,Zip) IV (City,State,Zip) Setbacks <br /> PHONE PHONE Site P pproval from <br /> !✓/" ap 'cable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS - <br /> 5k Floor ptgiis to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.d. 4 _ . - -/) <br /> PARENT PARCEL NUMBER: CU—tRRENT NING: ACREAGE: levatio f property <br /> ❑ NUM ER c 0 O — n 0 3�-ISS` ' )'1 // 6 7 oC S onta drawn to scale. <br /> TOWNSHIP: SECTION: <br /> �( <br /> 1/: /1/: N Drivewa ermits��r,�� { Stat ,county,town) <br /> n)ADDRESS: <br /> --) 3 C/7 S,ftkt h t/i Or- a,ev 1,-)2 5 3Sa s <br /> Sanita permits <br /> CSM: LOT SU DIVISION 1 BLOCWLOT (pub' ,private) <br /> f' /5 r\ /-,,k , <br /> PROPOSED PROJECT INFORMATION . �aa <br /> PROJECT DESCRIPTION: pis s tE) <br /> . ❑This project is a new building or structure. 0 �Use?� A <br /> This project is an addition/alteration to an existing building or structure. �, ` ; < <br /> lig SANITARY SERVICE: PERMIT NUMBER: • i, <br /> ❑SEWER • SEPTIC 9 90 3'7D ;F� f $ ' ° ` /4:M4 fi <br /> HEIGHT IN FEE NUMBER OF STORIES: (Not including basement) ,� '* <br /> ha t <br /> AREA TO NEAR EST SQUARE FOOT: ,:f <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) .� .s <br /> � <br /> BASEMENT: 1ST FLOOR: • ' • , T s <br /> TOTAL SQUARE FOOTAGE ; ', -i•! ': <br /> 2ND FLOOR: 3RD FLOOR: 1 (41-1 <br /> .if#49CStt• gyp <br /> ESTIMATED CONSTRUCTION COST: ( 1 ,,,�, ; cif, ,• <br /> ' (Please round to nearest dollar) '0 "♦ ♦ '� "♦ ♦ $ Coe, i } <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes i4 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) CI Yes tA,No ❑Don't know <br /> 7. Is this to correct a violation? CI Yes .ems No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ -i <br />