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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 /� l <br /> C_..- ` .r e.,S r Q T Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State!,Zip) Deed Restriction;CSM <br /> //5 L / �1 e ' r kok D e ; � �L 535 5 I <br /> ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> t/O8'7(941"5737 at,,j< b n.t_,c‹.m Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ck-wt'e- ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ • an approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) [Elevation of <br /> PARCEL <br /> t.))-41 property <br /> Y PARENT PARCEL NUMBER: CURRENT ZONI *,: r ACREAGE: �❑ NUMBER /0 7� a. -caSi- &q C ...." I / ' 7 <br /> frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> '-'aw;.k o �„c..a.r. , I 1 <br /> © s 1/4: E '/41/4: sw ❑ Driveway permits <br /> ADDRESS: <br /> 115q 1\) .S e',1,,,\ 1� <br /> CSM: LOT SUBDIVISION g- , <br /> BLOCK/LOT Sanitary permits <br /> .� (..ublic,private) <br /> C) 3(oCa 4 <br /> PROPOSED PROJECT INFORMATION <br /> t,.r -- <br /> PROJF�CT DESC�IPTION: ��, s4 <br /> . LThis project is a new building or structure. <br /> x:44-04 - aStr 07 0 <br /> This project is an additio alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: e-I, e•, n0_. exi i '° <br /> ❑SEWER SEPTIC 4" <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) k f_ <br /> ffi ® i- <br /> AREA TO NEAREST SQUARE FOOT: �( <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) '- ro '� : <br /> BASEMENT: 1STFLOOR:\3 0� a so * �i <br /> 0 4, TOTAL SQUARE FOOTAGE: 4, *o *F * * ” 0 <br /> 2ND FLOOR: 3RD FLOOR: ( r <br /> ESTIMATED CONSTRUCTION COST: _4,20;g1,' t : . .I <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ , � ; � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes allo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes Q'No ❑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 3 No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan 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.f , i?Gi e----- <br /> (Continue on Back) -+ —► <br /> 545-112(4/08) <br /> R <br />