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1, 7 t ,I. )� SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME be._,11 c3c Y r r / 4 q a,Ni _ ❑Zoning Status; CUP; <br /> OWNER ADDRES (Number,Street,City,St ,Zip) Deed Restriction; CSM <br /> �0 �Z-°t �` WL/ /� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6Og"z2s-Z/2Z ifGtrr ; .,>1 - Q,, & a , ,Ga0, Ili Site Plan drawn toscale <br /> AGENT INFORMATION CONTRACTOR I!iFORMAf1ON 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 /> n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusl) 111 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 173/ g nO/ / 3-47 ,- // s 6 g / frontage drawn to scale. <br /> NUMBER d b s ti//— pCf 2i d <br /> TOWNSHIP: SECTION: <br /> MI a7 7 �1�q.� ` ,4. , , n Driveway permits <br /> t �4�4 (state, county,town) <br /> ADDRESS: <br /> /O229 11w Li /ti <br /> YY1Q7-omQvt,'c ❑San ��n� <br /> CSM: LOT SUBDIVISION BLOCK/LOT ,�v`�� <br /> (pu II rlv e <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . -XThis 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 REPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Z / ; c./' ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 1—, <br /> ErosionControl permit <br /> '' /X `7; 5 / j TOTAL SQUARE FOOTAGE: 1 (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: J filling/access) <br /> I L 2,0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q� and available options. <br /> (Please round to nearest dollar) ♦ -► '♦ $ z n ) 0 O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves 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) rfres gNo ❑Don't know <br /> 7. Is this to correct a violation? nYes ONo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br /> i <br /> 1 <br />