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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER AME " \\ <br /> Ni 14.G r.G " a6 c o A\iciN ❑ Zoning District <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> '- %b SLoolf;.► S4 A . - i`�%cU� 4.on I S SSCo a CI Permitted Use? <br /> PHONE E-MAIL ADDRESS <br /> '� d. - 90.2 - a 14-0 ❑ Zoning Status; CUP; <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restriction; CSM <br /> AGEM CONTRACTOR NAME <br /> , � rA-� (3\co "vL . ..44 /Ubbe. ,,A, 1 Variance(# ) <br /> r <br /> AGENT ADDRESS CONTRACTOR ADDRESS ❑ Site Plan drawn to scale <br /> 71`14 kc'joc-1 and includes dimensions <br /> (City,State,Zip) (City,State,Zip) <br /> )1:c_14 le ( •■+ ( 53>G a ❑ Site Plan including location <br /> PHONE PHONE of well/septic <br /> COGS_ $fit- 1-1L-1, <br /> E-MAIL ADDRESS E-MAIL ADDRESS • ❑ Setbacks <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.diane.wi.usl) ❑ Site Plan approval from <br /> PARENT PARCEL NUMBER: ZONING: ACREAGE: <br /> ❑ PARCEL applicable township. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> SIP: 1 LI Rural Address <br /> 1 l ikle 1 oe '/4: 1/41/4: (new/existing) <br /> ADDRESS: <br /> ❑ Floor plans to scale <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> J V '.e t •sAIXieS ❑ Elevation of property <br /> PROPOSED PROJECT INFORMATION frontage drawn to scale. <br /> PROJECT DESCRIPTION: I <br /> Qc�.A.,-\-∎an CS Cre.e.n ch <br /> ❑ Driveway permits <br /> . ❑This project is a new building or structure. (state, county,town) <br /> X This project is an addition/alteration to an existing building or structure. <br /> ❑ Sanitary permits <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> (public, private) <br /> ❑SEWER ❑SEPTIC <br /> HEIGHTJIJ FEET: Q NUMBER OF STORIES: (Not including basement) ❑ Wetland/F000dplain/ <br /> �4 Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 0 1STFL0 4, (slopes, disturbance, <br /> i TOTAL SQUARE FOOTAGE: 4, C p <br /> ,� J filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> S6 <br /> -," i--- <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ c 10 / � and available options. <br /> (Please round to nearest dollar) =,L WO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No LI Don't know <br /> 2. There is a wetland or floodplain on or near the property? ❑Yes a No ❑Don't know <br /> 3. Have you talked with the township about your project? ❑Yes RNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Li Yes f'No <br /> 5. This project is associated with a rezone/CUP/variance (petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? ❑Yes 0 No ❑Don't know <br /> 7. Is this correcting a violation? ❑Yes ar,No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -■ -s —► <br /> 545-112(1/08) <br />