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■ <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 11 rMe3 'Mo>I-3 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> X7 U I W, V4 IanC ��0 Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONg. CELL PHONE E-MAIL ADDRESS <br /> 4 T5-- 3ba <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S14 -S 4OoJe- ❑ 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 /> LI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 0 5 I 0_' 3--�S - frontage drawn to scale. <br /> NUM <br /> TO NSH(IP: 1.., SECTION: ❑ Driveway <br /> fit"(_Gi✓�k) 1/a: '/a'/a: ypermits <br /> ADDRESS: � ��� � (state,county,town) <br /> Lhox try V-vqn.i L J 1 S F, a-1 <br /> ❑ Sanitary permits <br /> CSM: D��� LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION —g:t- ' <br /> PROJECT DESCRIPTION: <br /> ❑This project is a new building or structure. ' ,, ' � 3 , <br /> ❑This project is an addition/alteration to an existing building or structure. ..R _ '2,�• <br /> SANITARY SERVICE: PERMIT NUMBER: rV e a _t« �,1 <br /> ❑SEWER ❑SEPTIC s ° a a V- <br /> HEIGHT IN FEET: 1 NUMBER OF STORIES: (Not including basement) . ' <br /> } a <br /> ° s -- V <br /> AREA TO NEAREST SQUARE FOOT: s r ,, F V ,„ <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ". " -r <br /> BASEMENT: 1ST FLOOR: W �i -1 g� <br /> 4, TOTAL SQUARE FOOTAGE: 4, ry [4 <br /> 2ND FLOOR: 3RD FLOOR: 5 7(0 <br /> 1. k 1m ` v - s <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) "■ ♦ ♦ ♦ "♦ S� '1, v m - , n <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes litNo LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes m No Er 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? EYes ❑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 o n No ❑Don't know <br /> 7. Is this to correct a violation? LI Yes ANo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) `,�, <br /> (Continue on Back) —► --10. <br />