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. 1 <br /> /4.,..Ar?_��� ; &o � � <br /> P. t <br /> T SUPPLEMENT to Web•App # <br /> ZONING PERMIT APP (CATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE _( <br /> OWNE AME �}/` ,^ I I( 1— <br /> �\ C \Q \ \t. t 1 LW 1 D Zoning St to ,CUP; 4 K\C . <br /> OWNER ADDRESS (Number,Street,City,Sta e,Zip) `� x Deed Res I tion;CSM 1" <br /> HOME PHONE� ��CEpL PHONE E-MAIL 1 ���� �' •L7J� Variance(# vo <br /> 0 1" S O\-0 1`a l 9 i ± M �\Z, Y'n C i 6 I i L Site Plan % to scale <br /> • <br /> AGENT INFORMATION CONTRACTOR INFORMATION';:; and includes dimensions <br /> AGENT NAME CONTRACTOR 2 NAME <br /> 1 f\ S \ c O Site Plan in ding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/se is <br /> (City,State,Zip) (City,State,Zip) El Setbacks �` 51 ('c a I <br /> PHONE PHONE ❑Site PI •,t∎ .val from <br /> applica • ship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS f <br /> ❑Floor p n to scale <br /> PROPERTY/LOCATION INFORMATION (http://acet7.sleiane.co.dane.wi.ui/) Elevatio of p perty <br /> PARENT PARC • -': ': CURRE.T l'NING: ACREAGE: <br /> PARCEL r , (� (� W\ Q / frontage a n to scale. <br /> ��_,�� _`��GN_",�� <br /> TO ;J H_IP: • /J;SECTION: <br /> J�\C\S\C'\ C>�(1.. (//'`� ' : 1 � ❑Driveway per <br /> ADDRESS: .\1\ C1 /4/4 (state,co ri t.w <br /> t\ b �, \ 1 k ••)v( 1\ U1 Vy 1 S3 S�1 ❑ •Sanitary p its r�\� <br /> CSM: LOT SUBDlvts BLOCK/LOT (public,pr a ) <br /> PROPOSED PROJECT INFORMATION - STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning Di`s\r ct - <br /> . ❑This project is a new building or structure. ❑ Permltt'El-This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U.Rural Address <br /> EWER FIEPTIC (new/ex f�) .. <br /> HEIGHT IN FEET: �� V v V NUMBER OF STORIES: (Not including basement) _ <br /> ❑ Wetland/Flo/Ilk:L if <br /> Shoreland` • merit) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ Erosions s-. tr•I permlt- <br /> I.555 4, TOTAL SQUARE FOOTAGE: j (SIOp .l rbance <br /> 2ND FLOOR: 3RD FLOOR: fill- /ac e4 <br /> 4" � 5 ❑ Re4Ci, o tl•n Survey <br /> ■ESTIMATED CONSTRUCTION COST: 6- ( U and a\ II• .ptl mns <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ �)�V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres a. ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes 7 No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Elves QNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Lives k& o <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) / �i2 -s i%P.4'• ['Don't know <br /> 7. Is this to correct a violation? Elves IS4No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ —► -4 <br /> 545-112(4/08) <br />