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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> CUSTOMER TO PROVIDE <br /> OWNER NAME fi <br /> Ong ESSEX-- <br /> �J ❑ Zoning Status;CUP; <br /> OWNER�DRESSS (NN POW ly,state,Zip) ,/� -D �GupilA4 /4L Deed Restriction;CSM <br /> HOME PHON op CELII PH ��(r v/,//E-MAIL ADDRESS �! I S 3,'C'�f 7 Variance(# ) <br /> .73 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO .A'�O-�E M <br /> �- froyop7141,,, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> t ❑ Setbacks <br /> (City,State,Zip) (City, w te Zip) ,� /� <br /> PHONE PHONE ❑ Site Plan approval from <br /> 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 /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ❑ Driveway 1A: 1/41/: y perm its <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ig PR C/Ii,kPTIOG,V i44e_ Ai 2 1O ,, i-� r <br /> • ❑This project is a new building or structure. <br /> his project is an addition/alteration to an existing building or structure. :., = <br /> SANITARY SERVICE: PERMIT NUMBER: : , A®s <br /> ❑SEWER ❑SEPTIC <br /> �r.` 33 P R <br /> H5IGHT IN FEET: NUMBER OF STORIES: (Not including basement) £ ,'F- ': <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) - p <br /> BASEMENT: 1ST FLOOR: ® �! � <br /> { �?() j TOTAL SQUARE FOOTAGE: , <br /> 2 D FLOOR: 3RD FLOG t ® °, <br /> %' 2- �l� Xl� `/7 k <br /> ESTI�N ATED CONSTRUCTION COST: $ <br /> ♦ ♦ --► ♦ ♦ --► <� a sae a <br /> (Please round to nearest dollar) �- 'n. .� �q <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ❑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 , o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes L?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 L No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />