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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ONJER NAME <br /> VON 4- i Jt(C MA[-tom(t) ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City State,Zip) , <br /> 3r%, 3Ay LPvt2E L L, vL ?y& /VAc 141/: Deed Restriction; CSM ) <br /> 35q 3 variance # <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / <br /> tI PIZICICS� L L(. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 6 7/9 SE /7OLj R) <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> PHONE PHOlsONt 53717 El Site Plan approval from <br /> 603-'12z_5/no applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> C elSW ?o N , h'el I /(KS ,(Ur"I ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER a3�'/o7C�'-203-©d(,-O <br /> TOWNSHIP: SECTION: <br /> /4: ,/4,/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: pp <br /> 3 SrSd.� 5(ie-E-/U foci+ ❑ Zoning District <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> giThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> F1EWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Mme/-}&/ /2— i ❑ Wetland/Floodpiain/ <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: 1 ST FLOOR: ❑ ErosionControl permit <br /> +, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 210 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: /�� � and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ $ 3D(/ © �— <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es ❑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) Ekes No ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i <br /> 545-112(4/08) <br />