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,T1 I e nq kt SUPPLEMENT to Web-APP# <br /> ERMIT APPLICATION www•countyofdane.com <br /> ZONING P„ OFFICE use ONLY <br /> PROPERTY OWNER INFORMATION ^ �� Zoning District <br /> OWNER NAME . D L1 - c o �4Ie ' �' <br /> 1Vot . ^ T <br /> OWNS' •DDRESS (Number,Street,City, <br /> State, <br /> / ' ✓i►, '� D jtn W/ S3 /A © Permitted Use?' <br /> E-MAILADDR SS y, ��� .� Zoning Status;CUP; <br /> PHA I �i. G L�.d� Deed Restriction;CSM, <br /> 2.�N O s�' N CONTRACTOR INFORMATIO[J Variance( ) <br /> AGENT INFORMATION CONTRACTOR NAME / , � <br /> X/Ni I- t' f� -< <br /> ' vu n Site Plan drawn to scale <br /> / / / -•CTOR ADDRE S Q /D� <br /> i. . co ` J and includes dimensions <br /> AGENT ADDRESS O / �••/ .; Q Site Plan including location <br /> (.ty, .te.Z�•)rOki . / �.9 , PH'NE_/ of well/septic <br /> PH• E /'fib- / © SetbaCkS <br /> d(/ -MAIL ADDRESS J�� <br /> EMAIL AD�R'T / A o i�n t'^ /' f/ 4 b va from <br /> �, 'Thai* - �G LL <br /> -' appli( ble tcinsh .` <br /> ERTYILOCATION INFORMATION (ht Z�oNINGCessdane.co.dane.wi.us� Site Plan apRro <br /> PROP <br /> PARENT <br /> O <br /> Li PARC• Rural Address NUMB SECTION: <br /> TOWNSHIP: t�a:___— t�at�a:_----- (new/existing) <br /> ADDRESS: 0 Floor plans to scale <br /> IIINIIIIIIIIII SUBDIVISION BLOCK/LOT <br /> LOT a U Elevation of property <br /> frontage drawn to scale. <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT•ESC'PTION: t"d La —.rt. k 1I� ^ U Driveway permits <br /> S r 1 Q/ D Kr(( (state,eour�ty,town} <br /> e This project is a new building or stricture. Sanitary permits <br /> ❑This project is an addition/alteration to an existing building or structure. (publte,pnvate) <br /> SANITARY SERVICE: SEPTIC <br /> - SEWER ❑ WetlandfFloodplaint <br /> NUMBER OF STORIES: (Not in uding basement) Shoreland (attachment) <br /> ■ <br /> AREA TO NEARES QUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) [] ErosianConhOl permit <br /> (SIBS'disturbance, <br /> peter <br /> BASEMENT 1ST FLOOR: 1 TOTAL SQUARE FOOTAGE: j. ( lopes,di ss) <br /> 2 219/ ' `e <br /> 2ND FLOOR: 3RD F OOR: <br /> �C� Z I0'�i l.3'1 f C] Review Location Survey <br /> Z' a 2 and available options. <br /> ESTIMATED CONSTRUCTION COST: ♦ -► ♦ • <br /> .♦ -� -► 'il� �� <br /> (Please round to nearest dollar) ` &t, <br /> D Yes ❑No ❑Don't know <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond o - �'No Li Don't know <br /> 2. There is a wetland or floodplain on or near the property? Yes es ❑No <br /> 3. Have you talked with the township about your project? the past 5 years? ❑Yes UNo <br /> 4. Has there been a zoning permit issued for this property in(petition/appeal# —) (leave blank if none),� <br /> 5. This project is associated with a rezone/CUP/variance(p ❑Yes ❑No i�on't know <br /> 6. Is a location survey required? ❑Yes ado <br /> 7. Is this correcting a violation? <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -♦ <br /> 545-112(1/08) <br />