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I <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA <br /> D <br /> c.. - r?'" ' raw, LC-1 <br /> �Q Zoning Status;CUP; <br /> OWNERADDRESS (Number,Street,City,State,zip) Deed Restriction;CSM <br /> Z E yl /ry /"/ P A 1 1-1,,r; $'s-72. variance(# ) <br /> HOME PHONE CELL PHONE/ E-MAIL ADD 1-1,,r;RESS / <br /> '#8' 517 ."9/ r ,'4,e- PA ' fitA-444 6 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Q Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) NJ Setbacks <br /> PHONE PHONE &Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRES E-MAIL ADDRE <br /> et Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of r0 <br /> PARENT PARCEL NUMBER: CURRENT ZONING: A REAGE: property <br /> NUMBER D(t 0 3 r 16( -”15-6 1,c- ( ,d; 4ceei- frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> cOf /('�'IA: 1/41/.: 4 Driveway permits 0)/4-ADDRESS: (State,county,town) Q1Ll <br /> cii �Oct,"' id"7 ? gP Sanitary permits <br /> CV:L r LO SUBDIVISION BLOCK/LOT (public,private) <br /> e 0( csw■ i7lq 4, Car) it)(A +lr /� <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ale-id ❑ Zoning District <br /> . af 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 /> ❑SEWER ((( ___ SEPTIC �(''y, (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3 ( ❑ 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: 1---, ErosionControl permit <br /> it)d 4 . 3 ,DQ 0 , TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> r filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Na Ake Nvfv e 3, 6 00 <br /> ESTIMATED CONSTRUCTION COST: / ❑ and Review Location options. <br /> Survey <br /> (Please round to nearest dollar) -► ♦ -► -►• -I. -► $ �o D and available options. <br /> / poD . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Flo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ®No Po r 4-",-14,-14. <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# qfa-3 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) 4Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ID Yes 1 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4. -► <br /> 545-112(4/08) <br />