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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 6 f)R e ry 5 7 ,4 F mg Status; CUP; <br /> jOWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> as 5$ 4)2'64,'r/q'?'aiV {q /7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 46.3'"x,3'3 <75-,c,4OS aO4 `tea 1-f Site drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S' Plan including location <br /> AGENT ADDRESS CONTRACTOR DRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) acks <br /> PHONE PHONE ❑Site n royal from <br /> appl. township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [4,F,kf6EFrans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) E ation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> PARCEL frontage drawn to scale. <br /> NUMBER 0‘// ,.1-4 1 Q53.S0 4—,!.2 ( <br /> TOWNSHIP: SECTION: <br /> I"/eQ $ 4,,,f- SPR, ,72 S '/a: '/4'/4: ❑ Driv-' -,un rrrtown <br /> ADDRESS: ( ry' ) <br /> t./A65 lJ rt Sh .7 -f 6"C , <br /> CSM: LO SUBDIVISION BLOCK/LOT ❑Sani = •'rmltS <br /> ` (. - , •rivate) <br /> PROPOSED PROJECT INFORMATION STAF REVIEW <br /> PROJECT DESCRI ION: /� ) <br /> 1 � 2S CG --.'�o)rr K e p1�G -- L,7 Z mg District <br /> . 121This project is a new building or structure. Q P fitted Use?' <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: D Rural Ad <br /> FIEWER EPTIC (new/ Is ng <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> We - •-••lain/ <br /> �� � AREA ONEAREST SQUARE FOOT: Sh• - • -ttachment), <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> l® Ero Co' •1 permit <br /> BASEMENT 1ST FLOG .c <br /> 1 1, TOTAL SQUARE FOOTAGE: 4, (SIOpeS + -turl3anc@, <br /> fillin• -ccess <br /> 2ND FLOOR: 3RD FLOOR: / <br /> / -G it Re - . L• .•n Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ J� and ay; �� options. <br /> (Please round to nearest dollar) $ G– <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑Don't no, <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ❑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? ❑Yes ❑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) Ekes ❑■o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ - <br /> 545-112(4/08) <br />