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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 <br /> ( VI Ow‘.04,S J c\ , ,,,, ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,Sta.te'�Zig) ` Deed Restriction; CSM <br /> �C5O �t ,∎kti..A.4 vti e-A. V�\I•Q-, b A0,,,,� oie W lad-{ 53574 Variance(# ) <br /> HOME PHONE CELL PHONE •E-MAIL ADDRESS <br /> goc6 57--,-2 -41701.60c,.5-7 3 L17 3, t avYi.' i ,->rc- t) itt5A),FowA El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTGR.hIFORMATION ':. 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 .(ht.tp://accessdahe.co.daite:wi.itsi) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL BER o 5b , -3r 1 -q,t -1 j� � '-,c� . S 7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> LV, ( Y4: WA: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: N ,1 _ <br /> e2 <br /> 5L 4.&Av���. � v-7 e4� Ili..�^X C'�isvt� V-A-, ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PR CT DESCRIPTION: - - <br /> ht CLG% t,9ctv� -er ❑ Zoning District <br /> . ['This project is a new building or structure. ❑ Permitted'Use? ' <br /> his project is an addition/alteration to an existing building or structure. z <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural AddreSS <br /> EWER EPTIC (3—a,p cr - 00c--) K (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: {Not including basement) <br /> k ` ❑ Wetland/Floodplain/ <br /> Shoreland'(attaclment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) • <br /> BASEMENT: 1ST FLOOR: ❑ ErosionCOntrol permlt- <br /> 5' 1, TOTAL SQUARE FOOTAGE: j (slopes,disturbance <br /> <76. C filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 115 t <br /> S ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q� �/ 0� and available options <br /> (Please round to nearest dollar) ■ ♦ ♦ ♦ ♦ d` 1/00(g); <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Oko ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑No <br /> 4. Has there been a booing permit issued for this property in the past 5 years? [Yes Rio <br /> 5. Is this project associated wifh a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes [ o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Eitcla A, <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -► -► <br /> 545-112(4/08) <br />