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12-0 SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.county fdane.com pp <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME [' p <br /> b / El Zoning Status; CUP; <br /> OWNER it if (Number,Street,City,State;Zip) <br /> /0 S i ithr S-- !")c.11'[,Ji c. LA' ok Deed Variance Restriction; CSM <br /> �� � � Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 601, - • —00 cc/•• • �ii'50 • R. a G,"",/• c'�'"` <br /> El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /, I�� �(��U — (,,.51„,•. ,,I us 11 4,, Plan including location <br /> AGENT ADDRESS CONTACTOR ADDRESS 6 of well/septic <br /> pt,i,Ili.•cA (.Z s))-1/4k <br /> (City,State,Zip) (City,State,Zip) g IJ El Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> 60 c ._ Z 6 p C applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING. ACREAGE: <br /> ❑PARCEL R)— _Z frontage drawn to scale. <br /> NUMBER • <br /> TOWNSHIP: SECTION: <br /> /h 44(0 _4 R '/: /VIA 1//1/<: 5e6 I Lt ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> /0 k( 4nr` 51- 6,//cL)I (f( )'5 1 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ( - (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> rO IC Sit t-d ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET/ I k NUMBER OF STORIES: (Not including basement) <br /> ti^ (7 2 Me-4./0 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 3 2 ----: IL I 10 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: %J and available options, <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ) i 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es Dlo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes alo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes Elo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ao <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) . - m kn-tA v'`c dW^e_ ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Efres No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(4/08) <br />