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,9-5V it SUPPLEMENT to Web-App # <br /> ZONING PERMIT AP LICATI N www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN AME I L <br /> V$ s -9 0- - ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ��� y`� ST Rey/ 1 Variance(# ) <br /> H(ao?PHONE --3d !' CELL PHONE 33����E-MAIL ADDRESS ❑Site Plan drawn to scale <br /> AGENT INFORMATION Cs� CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO TRACTOR NAME <br /> CLe6, C/Ving CGr p ❑Site Plan including location <br /> AGENT ADDRESS CONTRAIOR ADDRESS / of well/septic <br /> Z -oX ' _FDA?a <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> t`Jtc 1.,1.) -.1.,1.) -.PHONE PHONE E ❑Site Plan approval from <br /> C.,08 B t1-r >U • applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: �/ 1 CU,RENTZONING: ACREAGE: <br /> ❑NUMBER © Z' l - v° I f') 3 / frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 1/4: 1/41/4: ❑ Driveway permits <br /> S r t�S � (° (state, county,town) <br /> ADDRESS: _ <br /> c9'1'1 3)- i -Q /c( Lin tAi //t ( 5 :- ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> 51C r .( Le / ❑ Zoning District <br /> . diThis 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 /> *� A ❑ Wetland/Floodplain/ <br /> O _ - nd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FL OR: ❑ rosionControl permit <br /> 1 D 4, TOTAL SQUARE FOOTAGE: , slopes,disturbance, <br /> Iling/access) <br /> 2ND FLOOR: 3RD FLOOR: �G <br /> �� ❑ R- iew Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ _♦ ♦ and available options. <br /> ♦ <br /> (Please round to nearest dollar) $ /5'- C-9-0C) <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 EINo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ales "jNo <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 12No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes MNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -* <br /> 545-112(4/08) <br />