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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OWNER NAME <br /> J t{4- / E.''''li 11.y e'/ 1 Zo 'ng Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D ed Restriction;CSM <br /> 1071 5+4ir 5 aoi Ro4•I 5-fou jh on h/7• Si 5-81 anance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> I <br /> (r0Q'- •9Z- 4111) J.�,2 , , erxrno t, inc. , nct Si Plan drawn to scale <br /> AGENT INFORMATION !CONTRACTOR INFORMATION a d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> A/if r 00 ,S)1 grS i e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> Ibame 91119 <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> )'1Lo+ells, k't. 13941 <br /> PHONE PHONE ❑Site Plan proval fr m <br /> (, 08- 5 b - 3059 applicab town p. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> rhprct4(( twirttrIS -(-C:.+. ❑Floor pl stosca <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL/NUMBER: 9 1 /CUURRENTZ VING: ACR G ❑Elevatio pro rty <br /> ❑NUMBER �'�J ! �V�/D�V fron dra t0 scale. <br /> TOWNSHIP: SECTI� <br /> R v.j-I q n A I 1/4: t■\ V -1/41/4: N \ ❑Drive y permits <br /> ADDRESS: (st e,county, n) <br /> I6 7 q 5-ii,./7 fC1,o?igi Sice ji,1ch L. 5''3 f�`I <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT ❑Sanita permits <br /> j / ( •ub'c,private) <br /> PROPOSED PROJECT INFORMATION e ',, 1 <br /> PROJECT DESCRIPTION: ' Z§ <br /> BJ=)(I 41 Zd x90 X»yri,►1,4.4 poz 1 <br /> I'This project is a new building or structure. ; <br /> This project is an addition/- eration to an existing build' • or structure. <br /> , <br /> SANITARY SERVICE: :: �;. <br /> x <br /> ..EWER C. <br /> • <br /> HEIGHT IN FEET: NUMBER OF STORIE': ( of including basement) At-n <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 /> 4 TOTAL SQUARE FOOTAGE: "4. <br /> 2ND FLOOR: 3RD FLOOR: r <br /> q0 0 , <br /> ESTIMATED CONSTRUCTION COST: / 0 D ': .. �I U <br /> (Please round to nearest dollar) $ 01 000. a v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? u -s at4o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? V es - ; o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes :n o <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) ❑Yes Elisio ['Don't know <br /> 7. Is this to correct a violation? ❑Yes 'lo°QD APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► -♦ <br /> w <br />