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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 /> 44V1 t°5 1< 1 + n (4 of '4 S A Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,Stets+ ) . Deed 2. O U Kc1 s <C✓ k C o t o ►31 low S iV .�.3 2.S- Variance(#Restriction;CSM ) <br /> \,./ HOME PHONE CE PHONE ' E-MAIL ADDRESS / <br /> ?2o- 2 - 822 '720-3 " -It 9- " .•owe„,rv"►eb.fri el- S' Site Plan drawn to scale <br /> AGENT INFORMATION ' CONTRACTOR INFORMATION <br /> -nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Tip) (City,State,Zip) _IA Setbacks <br /> PHONE PHONE A Site PI approval from <br /> appl" ble township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ..14 Flo/plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Ele/eva ' n of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P perty <br /> U NUMBER 01120139 310i A — 2, 1 qv Z s fron ge drawn to scale. <br /> TOWNSHIP: SEC ON: <br /> YO it K '/.: S C %oh: S ij Driveway rmits <br /> state, unty,town) <br /> ADDRESS: <br /> 2, o © (< a S p e./' p ot , Colic vY1 /0 u5, W.r 5325" <br /> Sanity ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ' 39,5- 2, - - (pu ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Y4 ,,,/ .S ti G or 1- '-x ( C aZoning District <br /> W-This project is a new building or structure. ermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural;•••'. <br /> ❑SEWER O SEPTIC ( _ ,/exi i ' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not inducing basement) /Co,-.,4' <br /> I`/ '— 9 '' q,)- S 1 6�Woetiand/Floodplain�� <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ErosionCOntrol permit <br /> I 9 Z 4, TOTAL SQUARE FOOTAGE: 4, (Slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> I <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -�► ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 8 �d <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? XI Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 4Yes ❑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/CUPNariance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes EiNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPUCATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -4. -► -► <br />