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---7 9_.i., <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �� <br /> /y� � e/ L 4` •oning Status;CUP; <br /> OWNERADDR SS (Nu be,Stree City, t zip) Restriction;CSM <br /> HOME PHONE J. I C ,� ,�/ E-MAIL P,icAue ' s-35-9 i Variance(# ) <br /> AGENT INFORMATION ��3 CONTRACTOR INFORMATION �• and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Seri tirg e i' Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS �/ e of well/septic <br /> (City,State,Zip) (City,State, ) p_1 Setbacks <br /> /17,64k40/141 5:17/3 <br /> PHONE PHONE ..) ❑ Site Plan approval from <br /> �•- ��J3 a.,5p#Pable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Ilk•Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ! Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ NUM ER Qs0P/',7901" g• • R- / 9 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 1 1/4: 1"! 4J 1/41/:J L.l ❑ Drivew permits <br /> ADDRESS: (sta county,town) <br /> s/S3-4 g 1 f ❑ Sanity permits <br /> CSM: LOT SUBDIVISION BL K/LOT <br /> 3 (pub• ,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: $ t <br /> . This project is a new building or structure. ,s-p. A This project is an addition/alteration to an existing building or structure. , ter �, .. <br /> SANITARY SERVICE: PERMIT NUMBER: f .�°.a � �. <br /> ❑SEWER ❑SEPTIC V W,I ' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �. � `3 = V <br /> tic ® r'` :A1 a iY. 9.. .ma " <br /> AREA TO NEAREST SQUARE FOOT: .. 4 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> t ,I 4, TOTAL SQUARE FOOTAGE: 4, `- P- �I t��,t ,4 4 <br /> 2ND FLOOR: 3RD FLOOR: `-T1) ® ' r <br /> Li ESTIMATED CONSTRUCTION COST: n, ® _"-� <br /> (Please round to nearest dollar) --► --∎ $ 5-ev, _�,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ;®No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? _a Yes CO No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? .®Yes ❑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 al No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -i <br /> 545-112(4/08) <br />