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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 e <br /> CILIA, SCr A .t(1-e,v` ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State, :1) Deed Restriction;CSM <br /> /0 Y4 niazvV�/ S L W I RZS60 Variance(# <br /> ) <br /> H/ PHO CELL PHONE E-MAIL ADDRESS <br /> ? n) o2 ' O$60 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wi.us/) ❑ Elevtiof <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> D PARCEL <br /> NUMBER UyCl6—aga -1S50-Lt frontage drawn to scale. <br /> TOWNSHIP: SECTION: ❑ Driveway VIIn.al YYlOL ikl.-e, '/4: '/.'/.: y permits <br /> ADDRESS: (state,county,town) ' <br /> )045/ (I \t' r\ _ ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION , ; $4 <br /> PROJECT DESCRIPTION: I „ *, ` 4 . ' �, <br /> P I A :. ►�� � at,-, .- ,- <br /> ❑This project is a new building or structure. ` ®�$_ � ,, <br /> la This project is an addition/alteration to an existing building or structure. :r. <br /> SANITARY SERVICE: PERMIT NUMBER: s ie�®° " <br /> � <br /> ❑SEWER ❑SEPTIC '' °" l:- :' <br /> HEIGH FEET J NUMBER OF STORIES: (Not including basement) s <br /> — uses'ar a` 9 ®.f.,_ ,k t E !�s^,, 4∎ '" <br /> f �' <br /> AREA TO NEAREST SQUARE FOOT: ,-.T,,,, "� --,,�, ,- <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , - <br /> BASEMENT: 1ST FLOOR: '' ai ® i �, w <br /> �— 7' ,, TOTAL SQUARE FOOTAGE: j <br /> 2ND FLOOR: 3RD FLOOR: ` <br /> ESTIMATED CONSTRUCTION COST: 1 r m ,g,:il <br /> (Please round to nearest dollar) -* --0 . �j$—/t 2((� _ IK - 7 ig <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IgNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes RzNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? AYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? llYes ❑No <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) ❑Yes 2 No ❑Don't know <br /> 7. Is this to correct a violation? CI Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -11. -► —► <br />