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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 i <br /> n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ���� �TCnz'`� l/ �� L/��'� �� `��� 75' Variance(# ) <br /> HOME PHONE CEL HONE E-MAILADDRES <br /> 6519955e ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGE AT NAME CONTRACTOR NAr ME <br /> L.��kOr U / / > 'k„ fro r ,6 41` /C <br /> ala I/vL n Site Plan including location <br /> AGENT ADDRESS CONTRACTOR AD RESS of well/septic <br /> ��jj . *14 a,1- S7 <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> 2/4-v,m. <br /> PHONE PH E El Site Plan approval from <br /> SQ-64c0 applicable township. <br /> E-MAIL ADDRESS E-MAILADDRE S <br /> �`, (r ' 1/4P:e.I le&14/C Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACR GE: <br /> ❑ PARCEL 0 C0 a l Li Z Q so on p`/„ 7 j ( 3(, frontage drawn to scale. <br /> NUMBER V F- t O <br /> TOWN/SH�IP: SECTI N: <br /> 1/4: ,/4,/: ❑ Driveway permits <br /> A ESS: (state, county,town) <br /> ..e-e_74 ki <br /> SM: LOT/ • SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public, private) <br /> d C <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /.Z, /4 y. ❑ Zoning District <br /> This 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 /> flSEWER EPTIC t 3- 20 ib- act 346 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /'g, ,- ❑ Wetland/Floodplain/ <br /> - o Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BA E r: ` �/ 1ST]FLOOR: _ ❑ ErosionControl permit LI z l6 't7 . b 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOG : ••.�j 3RD FLOOR r t". <br /> / �r�3s,z� �� \ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available options. <br /> (Please round to nearest dollar) <br /> 50oj V0 c <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? Mies ❑No n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ es ❑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# `0768 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes n No D15-on't know <br /> 7. Is this to correct a violation? ❑Yes j N-No <br /> c/ C9 /7 —( z3 Z APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ —1 <br /> 545-112(4/08) <br />