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0'73_ r-b <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 13 1 tC11 7,4 F . ❑Zoning Status; C <br /> OWNER ADDRESS (Number,Street.City.State.Zip) Deed Restrict. ;CSM <br /> Variance(# VV ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> A/6(1)AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME TT ACTOR NAME / <br /> 4 :* 1 I�.f4.f$- CO Oal " ue- ❑Site Plan includ��ng i6cation <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic Vv <br /> (City,State,Zip) (City.State,Zip) ❑Setbacks <br /> PHONE -')' /3 'a r .C.545`1.. ❑Site Plan approy�I r <br /> --� 10 9 -747- t 12 applicable tow li <br /> E-MAIL ADDRESS E-MAIL ADDRESS // �� <br /> -9 I ,,(?d2 jam, 1-ec./x-0s;earl ❑Floor plansale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dano.wLus/) ❑Elevatio Of Operty <br /> PARENT PARCEL NUMBER: CURRENT ZONING. ACREAGE. <br /> ❑PARCEL 101 R.--.. I frontage awn to scale. <br /> NUMBER <br /> TOWNSHIP SECTION Mtttor( 4 ftJ#IC,. '/4: Y4'/4: ❑Drivew p its <br /> (state.c ty:town) <br /> ADDRESS _> �7 ' <br /> C$M: ����LOT V 6��NISIO 6 BLOCK/LOT <br /> ❑Sanitary permits ( Lf <br /> ?W e i l,* t (public,private) �;Y�J LC <br /> PROPOSED PROJECT INFORMATION STAFF:REVIEW <br /> PROJECT DESCRIPTION , t ! <br /> l�C,tc,) CO 1 0 Zoning District <br /> . EThis 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: ❑ Rui -.... ` <br /> EWER [EPTIC (nc <br /> r - <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> I vv� j ❑ Wetland/Floodplain/ <br /> lAREATO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions in ng unfinished area,attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT 1ST FLOOR: �j''�f) <br /> I f / e1/ rrot O 4. TOTAL SQUARE FOOTAGE: 4. (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR 3RD FLOOR: <br /> _. . l ❑ Revi W •. rvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ oc► and • opt,ns. <br /> (Please round to nearest dollar) /i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [ io ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [—Yes `A o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes 'lo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le ve blank if none) <br /> 6. Is a location survey required? (see reverse) •52► -s ( Vo ❑Don't know <br /> 7. Is this to correct a violation? es ( No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —b. —+ -+ <br /> 545-112 14108) <br />