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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 /> Qu--A 4 g /<< Zoning Status; CUP; <br /> OWNER ADDRESS (Nu ber,Street,City,St t,Zip) Deed Restriction; CSM <br /> fit y-- F /y�, r Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> r7S` -a•3 a 5._,►S 7e' 4,4 •r"11- Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENTNAM v //t-,c CON ACTO NAME <br /> t> v i, -.'�er!, �j Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS e of well/septic <br /> z_1 Co--./-y c & = Z3(5 C�.-A rt..- AA_ /-`1 / <br /> (City,State,Zip) (Ca 5-c a zip Setbacks <br /> j� �..T 5-3r�s- <br /> 4,`"/ ' �S c'�G{ Site Plan approval from <br /> PHONE PHONE' <br /> 5--r-r- 766 Z 08 -6-71y - 7G 2- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 74„`■.5 , h..).,, -c'--.€>/►^6,,1,,L...iJ c .c Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation of property <br /> PARENT PARCEL NUMBER: CURRE TZO/NING. ACREAGE:I Z + frontage drawn to scale. <br /> PARCEL b� /6O �•5;i ecZ 0 _ 1 Z�! ' <br /> N:'MBER a <br /> TOWNSHIP: SECTION: , t ,4,% Driveway permits <br /> (U o•_i-.-0S,�- �4 � (state, county,town) <br /> ADDRESS: <br /> /1$7 , -viz, -f,-„'1 Sanitary permits <br /> CSM: LO SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRFTION: <br /> ❑ Zoning District <br /> . This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to'?n existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address <br /> -Zs— SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) ❑ V110tland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 0=ErosionCOntroI permit <br /> BASEMENT 1ST FLOOR: <br /> SOTAL SQUARE FOOTAGE: ( es,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: J <br /> _ ?2,e ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ' and available options. <br /> $ <br /> (Please round to nearest dollar) 7 2 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes k 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? Ygi No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? eNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. IR a location survey required? (see reverse) Yes eto Don't know <br /> 7. Is this to correct a violation? Yes 29 <br /> APPLICATION MUST BE SIGNED <br /> (Continuo on Back) <br /> 545-112 44/081 <br />