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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION C' STOMER TO PROVIDE <br /> OWNER NAME <br /> 15e`cicf4 SS'Gte Jov+I Jc15 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 9 <br /> \_,--- 60o ;v, 5t- 5 04 pfr,;i. ' i 5 3 5 2' Variance Restriction; CSM <br /> e(# ) <br /> HOME PHONE CELL PHONE , E-MAIL ADDRESS <br /> 60'6"G 85.77 Ob fin c•✓ 7)co a )--6,1, co/v) Site Plan drawn to scale AA <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions • <br /> AGENT NAME <br /> CONTRACTOR NAME <br /> 13 r (44 n g i kt s <br /> e Plan including location <br /> AGENT ADDRESS � , , I <br /> CONTRACTOR <br /> ADDRESS of /septic <br /> G, ct ova SZ,r•g— ct 5 et 0;`t. <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> {ONE PHONE ❑Site Plan a royal from <br /> \ applicab ownship. <br /> E-MAIL ADDRESS . E-MAIL ADDRESS `1d <br /> loor s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER:1 C IG: ACREAGE: levation of property <br /> ❑PARCEL O II O / ' 'Piet rontage drawn to sca <br /> le. <br /> !NUMBER <br /> rOWNSHIP: SECTI <br /> /4: ,/4,/4: Drivewa permits <br /> ° G`cl�- ``�'� (sta , county,town) <br /> ,, r Le ('/ L <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pu <br /> lot /0 �)otTAr;J 0 k <br /> PROPOSED PROJECT INFORMATION EVIEW <br /> PROJECT DESCRIPTION: r L <br /> Uv s, ,6_C 4 brie__ onin 'et <br /> . 2This project is a new building or structure. ermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> 4 ' Address <br /> SANITARY SERVICE: PERMIT NUMBER: i�( 03 a )-v WOW ting) <br /> ^� JJJJ r-� � <br /> EWER EPTIC <br /> /EIGHT IN FEET: / . Q NUMBER OF STORIES: (Not including basement) <br /> J W d/F dplain/ <br /> Sho d (attach t) <br /> • -,EA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: / 1ST FLOOR: / -i Erosl•,Con .I permi ' <br /> 2ND FLOOR: �r 3RD FLOOR: 31115 S Tr TOTAL SQUARE FOOTAGE: l (slopesturbance, <br /> Review Location Surve, c' <br /> ESTIMATED CONSTRUCTION COST: U and available options. . <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ° ©3 p <br /> IP <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't k ow <br /> 2. Is there a wetland or floodplain on or near the property? [Yes C N ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? "MYes ❑ i <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) ❑Yes ❑No [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(4108) <br />