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2A ace <br /> , . <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION` CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> JI) 1VA /d L, /MA Y� ❑ Zoning Status;CUP; <br /> OW ERA DRESS(( umber,Street ,State,Zip) y Deed Restriction;CSM <br /> ?.3 ( Street <br /> _ Variance(# ) <br /> -•ME- O GILL PHONE y / E-MAIL ADDRESS <br /> 1 i 6r7 5 /0C _b g Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG NAME CON TOR ,` <br /> ji t /�; �,�% IJ Site Plan including location <br /> ABEN ADDRESS <br /> 7 3 , J /< CONTRACTOR DDRESS of well/septic <br /> (Ci Ite, ip L(� (City,State,Zip) L'7 Setbacks <br /> NE / PHONE ❑ Site Plan approval from <br /> ice' v/ S3 6 -3 5 applicable township. <br /> E- IL ADDRESS E-MAIL ADDRESS <br /> Ly Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) vation of property <br /> PARENT PARCEL .UMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ NUMBER U56 D'6 U 1S -guy'11$4-,-6 frontage drawn to scale. <br /> TOyyNSHIP: SECTION: /// <br /> Jj/ o g %,:_ /1/�/ %,A4. 5 W LI Driveway permits <br /> (state,county,town) <br /> AD ESS: /? I/ey—/� / ' //,./.4- <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION A ,4 <br /> � . �- <br /> i; v` <br /> PROJECT DESCRIPTION: <br /> L= his project is a new building or structu re. - �,- ,- - ' <br /> • ❑This project is an addition/alteration to an existing building or structure. ,. <br /> SANITARY SERVICE: PERMIT NUMBER: �i e a ., <br /> �l �e ,.- C <br /> ❑SEWER ❑SEPTIC ° s � <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: , �� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) `""• , #"' , ' <br /> BASEMENT 1ST FLOOR: / <br /> At...,/ �� +, TOTAL SQUARE FOOTAGE: ,l 3 4f.2ND FLOOR: Z 3RD FLOOR: i/ ((/ �j� /� �) <br /> a � E <br /> ESTIMATED CONSTRUCTION COST: ,-, �,�D e, <br /> (Please round to nearest dollar) -► -► --► -4. -+ $ / < p 5. - 1 4; ,:. ., <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,L�J,N ,o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes lld'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Y�❑ s ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? IJ�Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank i one) <br /> 6. Is a location survey required? (see reverse) ❑Yes NNo ❑Don't know <br /> f <br /> 7. Is this to correct a violation? ❑Yes f(io <br /> #g g APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -► <br /> 545-112(4/08) <br />