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,....it, SUPPLEMENT to Web-App#
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNE; NAME
<br /> a 1101 j c oning Status; CUP;
<br /> OWNER ADDRESS (Number,Stret4y,State,Zip)
<br /> Po 23 to �` /�to , / L. �2S1 Z Deed Restriction; CSM
<br /> HOME PHONE x CELL PHONE dal.
<br /> E-MAIL A�DRESS� variance(# 2 )
<br /> AA. ---1.J3`y1S1/ J •,1-► i7as M ite Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> "" : 115 c9-,- ite Plan including IocatiQ y/�
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic V/ 1
<br /> (City State Zip) it (City,State,Zip) etbacks
<br /> PHONE PHONE Slte PI" ..mDQVal from
<br /> (aU� _333`-y/CL/ applic.•l- ownship.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> C--1, a ? 5,� _ p1 ^- Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property
<br /> PARENT PARCEL NUMBER: CURRE�TZONING: ACREAGE: P P Y
<br /> ❑PARCEL �'�Cycc„di[J,� �'-r© e z cj.- J� s fronts drawn to scale.
<br /> NUMBER L
<br /> TOWNSHIP: 1 y r SECTION:
<br /> /4:J f_"�{, ** 1/4. 1/41/4: Newsy permits )pA
<br /> ADDRESS:
<br /> V(�/`(/l, (V ,�y, / f (state,county,town
<br /> Za:'� (AC � � / '1,rG�1 UB p.4 // �T -5-154' Z ry P
<br /> CSM: LOT SUBDIVISfON BLOCK/LOT snits permits l
<br /> (public,private) J�
<br /> PROPOSED PROJECT INFORMATION STAFF-REVIEW ''
<br /> PROJECT DESCRIPTION: r
<br /> sir �...-(c)o S q 0 y a So >n Dist ct
<br /> This project is a new building or structure. rm uSes£ '
<br /> ['This project is an addition/alteration to an existing building or structure.
<br /> iia Ad.b
<br /> SANITARY SERVICE: PERMIT NUMBER: t, ,��� � s ,�x
<br /> EWER [EPTIC (flew/e isting t, i rj.
<br /> HEIGHT IN FEET: 1 NUMBER OF STORIES: (Not including basement)
<br /> and/Fjoodplain/ w , A
<br /> M �� 1 Slioreiands(attachment),
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) u ;� r �
<br /> .11l l=r• eirl Ontro7 permit
<br /> BASEMENT: 1ST FLOOR: W`,"t S.i ..a��
<br /> 4, TOTAL SQUARE FOOTAGE , s1c es,disturbance, , ,
<br /> G filltr,,,:,;A:„...;,,,,,,,,, ,,,,,,,,,,,,:„cess `
<br /> 2ND FLOOR: 3RD FLOOR: ^ � sr'� ' ? a�
<br /> !A° y,! eview ocation Survey
<br /> ESTIMATED CONSTRUCTION COST: 6110 0 and av fable options ��
<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? Jcc Yes No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? EYes ®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 QNo
<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) es ao ❑Don't know
<br /> 7. Is this to correct a violation? [Yes No
<br /> (IJ APPLICATION MUST BE SIGNED
<br /> 11 "� W t (Continue on Back) -► -i -►
<br /> 545-112(4/08)
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