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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 /> 1 ,/ t M` (-..DatO ®Zoning Status;CUP; <br /> OWNER ADDRESS (Nu ber,Street,City,State,Zip) Deed Restriction;CSM <br /> 3 p t� S, ( S S-r".. t4' MT 140k , 6J/ Sj5-7 t Variance(# ) <br /> HOME PHONE CEL PHONE E-MAIL ADDRESS <br /> LOS) 1f 3`�- 4) '• (o a) 710--0// ®Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> &L.°L.° W ,i,141 ./t.A 00 14 R)(..A1,LD Cv ,-roM CoAmivic-riova Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS 1 of well/septic <br /> 2. (o 6 Ci)VON 2aao'S 7,5'66 COuArY /Zoan <br /> (City,State,Zip) (City,State,Zip) ®Setbacks <br /> U(ertnAlo. IA11 5 3.�5 3 V6no_uo. M 5.-3sq 3 <br /> P ON ) PHON I ©Site Plan approval from <br /> b(b) ZZS- 1914 9 (00 8) ZZS_/7 1 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 7rq I _ i i r 5 r h2rr 8rt.t.44 a.T N C. ' (P j ,k)(1- ®Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: W Elevation of property <br /> NUMBER MBER b5`f(�07-0' o) — ( !i. frontage drawn to scale. <br /> �2-4 7-. <br /> TOWNSHIP: SECTION. <br /> SW 1/4: kJ KV 141/4: sccuov Io ©Driveway permi <br /> SS: n►iQGAtr AL-U. (state,county, 0 <br /> ADDRESS: <br /> Z ry permits <br /> CSM: � ' �� LOT �� SUED ISI BLOCK/LOT <br /> ®S(public,private) <br /> 4L (p P ) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> N(.W kt)5C l 84,114WAY (o,1j-r,-v&.r o..A1 'Zoning District <br /> This project is a new building or structure. Eii <br /> Ia 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 1 (3. Lo((p---('o(l' 0/existing) <br /> HEIGHT IN FEET: J V ' / NUMBER OF STORIES: (Not including basement) ,-, <br /> It ��� /. J. cii tland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> 0 ErosionControl permit <br /> BASEMENT:- 1ST�FLOOR: <br /> 33 4 TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 3 filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1 Li 1 ii <br /> E Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ AA and available options. <br /> (Please round to nearest dollar) ♦ - $ Sa0 t10©,t/0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yes aio ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? :Yes alo IllOon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes Wlo <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 EINo UDon't know <br /> 7. Is this to correct a violation? :Yes EINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />