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f. --7 03 )-19 1 fij--\ <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> • <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME A - <br /> V e. (2_-' l a(i_ C.:IVY) 1 LL.-c ❑zoning Status;CUP; <br /> OWNER ADD SS (Number, eet,C , te.p Deed Restriction;CSM <br /> i r� 1 ) <br /> (U 01 11,O 1-P .t U L. I. •f ii Lac 11 Variance(# ) <br /> H9MO CELL PHONE E-MAIL ADDRESS <br /> �+YJ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION `CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> SAME A5 4166 V e ❑ 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-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTYILOCATZON INFORMATION (http:Uaccessdane.co.dane.wi.usi) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> 0 PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> rn'\ t ` (rn '/.: '/.'/: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: • <br /> Oa a 4L ❑Sanitary permits <br /> CSM: LOT r SUBDMSIO f BLOCKILOT (public,private) <br /> Z 4 I um (Jo <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: ' n ' <br /> . m'This project is a new building or structure. <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERV�EVVER ❑SEPTIC —^PJ�M%3 �, _ n � � — -- -- <br /> 99 <br /> HEIGHT IN FEET I 'NUMBER OF STORIES: (Not including basement) <br /> 3� 2o�1 Z P.- <br /> AREA TO1EAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and abov ra •�.'s or•orchea)' <br /> BASEMENT. / 1STFL00Q c ( 7iA1-Al,E AGE: 4, <br /> �ND� 3 7 3Rt7 FLOOrr/JR: + & G <br /> 1 3 7 d r3 O J <br /> (Please roun nearest es dolls COST: $ 4 35 1 )Ot <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes �No -0 Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes E No 0 Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? *es 0 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? iNlYes ❑No <br /> 5. Is this project associated-with a rezone/CUP/variance(petition/appeal# ) (le9ve blank if none) <br /> 6. Is a location survey required? (see reverse) UYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes �No <br /> APPLICATION MUST BE SIGNED . <br /> ' (Continue on Back) -4. -S. -* <br /> 515-112(4/08) <br />