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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N <br /> Ter1/4_ e ctot jet ❑Zoning Status; CUP; <br /> OWN DD (Nu�mber,St'f-et,Cityate,Zip 1- �^ Deed Restriction; CSM <br /> o" cl kil k(r f Ue • 5 1Ou 14. kA� tJL 53M Variance(# ) <br /> HOME PHONE C L�PHONE E-MAIL ADDRESS <br /> •V(J.' /A kG 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME C N RA,CTTO NA / <br /> AGENT ADDRESS CONTRACTOR O ri S� '�"Rrlte�Ck ❑Site well/septic <br /> including <br /> t e location <br /> de/-7, $. t4 gl( Dr p <br /> (City,State,Zip) (Cit State,Zip) El Setbacks <br /> ' x4/440 &.11 93efl1 <br /> PHONE HONE 7' ❑Site Plan approval from <br /> 6o0 -g'73 -08 /6 applicable township. <br /> E-MAIL ADDRESS E- AIL ADDRESS <br /> cl d. M c)4,,,,v4480404,1641,4,40/1,Cow. ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: / CU /RENT ZONING: ACREAGE: <br /> El PNAURMCBEELR 0 O,j El—09 3 -90, 1'� /1( Jt; 0666 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> AAAki r k- 5w i 1/4: 6w ,/41/: fl Driveway permits <br /> ADDRESS: (state, county,town) <br /> I fc.2 6 D41 A,','k /Ide, . iii yll i � '4', . 3 ID Sanitary permits <br /> CSM: LOT SUBDI(/ISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> L._C it 3 ❑ Zoning District <br /> . 01 his 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: ❑ Rural Address <br /> EWER )EPTIC (new/existing) <br /> HEIGHT IN FEET: ! NUMBER OF STORIES: (Not including basement) <br /> / ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> ,j, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ( 1 <br /> . (1)0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ /;,.�� �� and available options. <br /> (Please round to nearest dollar) / Ki <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Wes ao QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? eJYes Eto <br /> o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Ores Olo <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) Wes n o ['Don't know <br /> 7. Is this to correct a violation? QYes Ei o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) (Continue on Back) —► —to. <br />