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.. <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1 C"/ qe I C'- `' PeIIr ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) // Deed Restriction;CSM <br /> !`3 / Z t T/{ ,6/,3 Deer C,'-e a biJ SiSt/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> D 9 3 y/ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5-oli 4 a 17 7 t t ae4 ...44 S ee•-• ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) CI Setbacks <br /> 0.4?C�c.p ie Q W; S 3 s 3 / w 0‘ <br /> PHONE PHONE ❑ Site Plan approval from <br /> 4 o I- - 74- c - 5 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CUR NT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER 0)11— 1/Y-9 9 )10^9 Vs. IA <br /> TOWNSHIP: SECTION: <br /> t o � e / e•d,1 e 1/: 1/41/: ❑ Driveway permits <br /> ADDRESS: co (state,county,town) <br /> `j/Z C I ll 113 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: <br /> / / Yaa 5,,...,../ VC -z_ke O • : s , <br /> tfiojtibM <br /> . 2This project is a new building or structure. ffi <br /> ❑This project is an addition/alteration to an existing building or structure. wr �E <br /> SANITARY SERVICE: PERMIT NUMBER: VOT:84dres - N,g fA <br /> ❑SEWER ❑SEPTIC z eville <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> � �. <br /> AREA TO NEAREST SQUARE FOOT: <br /> ( <br /> vmep Outside dimensions including unfinished area,attached garages and above grade decks or porches) . i."- 14P-41-t ,,,,, :1, <br /> BASEMENT: 1ST FLOOR: � a ' <br /> N Q O j TOTAL SQUARE FOOTAGE + slop#% nc , <br /> 2ND FLOOR: 3RD FLOOR: - <br /> ESTIMATED CONSTRUCTION COST: <br /> a va as 4:01000-3M1 <br /> (Please round to nearest dollar) --► -4. -► -0. -∎ -► /5%000, O a . WNi a <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Llo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes L icro ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes Flo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ®< <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) LitYe-s- ❑No LI Don't know <br /> 7. Is this to correct a violation? ❑Yes Ri <br /> APPLICATION MUST BE SIGN <br /> 545-112(4/0e) (Continue on Back) -► -► ED <br />