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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> ' PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER Dou 4 c#1 S k f V i 4A Ai M. 1 'EA( IL/4''" <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status; CUP; <br /> 86 1 Nw v 5 1 5-7Du -r-D4 - 55-35gq Deed Restriction; CSM <br /> / DONE E-MAIL ADDRESS Variance(# ) <br /> HOME PHONE �EL <br /> 600 81.3-w0(05 bo$�333-J 99Q c • (pq a L'Pi4/113�.Wei Li Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NA <br /> 6(607t ( /L�61 , ,1 nu CI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> i I-4-0 11-ge 16 - 3oy32� <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Ix0wA1 WI 3:3 03(0 <br /> PHONE PHONE ❑ Site Plan approval from <br /> ci 2 0 - 2 6 I -915 I 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 UMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL ,1? 3 Z 5,4(33 Ae4E s frontage drawn to scale. <br /> NUMBER Q�� OS/1-(J �� ��� f� <br /> TOWNSHIP: p SECTION: F <br /> Da a it Klee - = ] li2. - de.,,%. Li Driveway permits <br /> ADDRESS: (state,county,town) <br /> 5'6 I I-lw v S <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> .71 ° 4 / (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . IUl 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 /> ❑SEWER ^ ❑SEPTIC iVV�Q (new/existing) <br /> HEIGHT IN FEET: e- NUMBER OF STORIES: (Not including basement) <br /> 2 0.5 o N E ❑ Wetland/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 /> BASEMENT: 1ST FLOOR <br /> ❑ ErosionControl permit <br /> 1I : <br /> N A D S + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: N/A 3RD FLOOR: / <br /> '� - A ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ -+ ♦ $3 g,20 OC/11 d ieRd_ <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? ❑Yes ®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? Li Yes ktil 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 X1 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -► <br /> 545-112(4/08) <br />