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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 6cc61 ROSP4 9'/'P/7 ❑ Zoning Status;CUP; <br /> OWNER ADDKESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ©3 4, hi. 4"./7/7P/IJc,G Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 77 -5 .8 1 ��'� , - • £'4/9// •I ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AOLMTIWWME © /7 r 4 C. a r' CONTRACTOR NAME <br /> 430Pe D <br /> �� ref's' ❑ Site Plan including location <br /> AGENTADDREgs CONTRACTOR ADDRESS of well/septic <br /> /3 D O S 1Uy'` 45/ <br /> (City,State,Zip) / (City,State,Zip) ❑ Setbacks <br /> k4/deoCS , L/`. �^`a'ilk <br /> PHONE PHONE ❑ Site Plan approval from <br /> 9,R O --775 - 51,a/...2 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> LI PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ,/. ,/4,/: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ° STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> G A 7/tiG- �0 ' '� <br /> . ./.e � v S t = District ����, <br /> - I a <br /> . ❑This project is a new building or structure. <br /> Perl�ttted Else? <br /> ❑This project is an addition/alteration to an existing building or structure. °` 5 <br /> SANITARY SERVICE: PERMIT NUMBER: Addr @SS <br /> ❑SEWER Li SEPTIC (naw/existing) � � <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) v <br /> WetlanddlFloodplaifin/ �'% <br /> Sho nd (attachment) ,; <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> C] r loin; trol permit <br /> BASEMENT: 1ST FLOOR: <br /> TOTAL SQUARE FOOTAGE: (slo S disturbance, <br /> 1 y fling ccess) <br /> 2ND FLOOR: 3RD FLOOR: 3 - <br /> Review ocation Surrey <br /> ESTIMATED CONSTRUCTION COST: d 1Vai);�je'optiobv <br /> (Please round to nearest dollar) . -P -0 $ -- •3 l o LVi .;: t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No LI 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 ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► ■ —► <br /> 545-112(4/08) <br />