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1.;.> (;" V <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE; NAME <br /> I I l plJ` S LI-L oning Status; CUP; <br /> OWNER ADDRESS (Number,Street, ,State,Zip) <br /> Deed Restr iction; CSM <br /> x (p203o :d L / � - 2s" Z Variance(# Al ' <br /> ) <br /> HOME PHONE CELL HONE E-MAIL AyDRES1 <br /> .-- -33.E-L/� 1 j •N-'► 4° `mss �'' <br /> S-',- ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and ' ludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -'3^ W: 15 S r Site Plan including Ik4 <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic J`�c <br /> 2'2 h 620.Euf <br /> (City,State,Zip) • (City,State,Zip) etbacks <br /> PHONE PHONE to Pla a•i l► al from <br /> (pVi' -333•- 1/- / applicaf. e` • ship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ■ t M iZ�S nv , , _ /y1 loor tans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn levation of property <br /> PARENT PARCEL NUMBER: CURRE ZONING: ACREAGE: P P y <br /> ❑PARCEL e' cy .-oi tt-t- _`8--0 ;E / f��4L�� frontage drawn to scale. <br /> NUMBER l CAW v (/fZ <br /> TOWNSHIP: SECTION: <br /> 44 k, 114- b•.� 1/a: s 1/1/:_r E • eway permits A. <br /> ADDRESS: (state,county,town <br /> Zcn Vc iv /vddjL 1 t' �� <br /> anitary permits LOT ,k 7T CS � DO OCKOT (public, private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S� .g�-.1�:•-.S 30 X�3COd 4Sing District <br /> . ISThis project is a new building or structure. VPer . ed Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Ural ':• -SS <br /> EWER rIEPTIC (new/- isti •) \V <br /> HEIGHT IN FEET: 1 5 6 it NUMBER OF STORIES: (Not including basement) �N{'`` <br /> nn '�. ,r\ I N etland/Floodplain/ - <br /> / v�AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) tai <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porchesoslonControl permit �,o%`� <br /> BASEMENT: 1ST FLOOR: <br /> l TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> ccess) <br /> 2ND FLOOR: 3RD FLOOR: <br /> /WO <br /> LJ'(Cew Location Survey <br /> ESTIMATED CTION COST: and available options.♦ —I. ♦ —10. —o. $ 0`I 60 v(Pleae round to nearest <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? Eyes f 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 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 /> ❑ <br /> 7. Is this to correct a violation? Yes No <br /> A (And-5 APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -∎ <br /> 545-112(4108) <br />