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VI-S SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME . /' <br /> �OY I`< 'i ( ,5 Yd ning Status; CUP; <br /> OWNER ADDRESS (Num er,S Feet,City,State,Zip eed Restriction; CSM <br /> 3 -7 7 q tO K P 7'1 I IR oi cpc.--n oYeS71- WI 53531_ Variance(# )• <br /> HOME PHONE CELL PHONE E-)M IL-Afp DRESS �} <br /> ,: �-=,- C.o i 3 7K I 101 i 1 Q loVC`�`2-2- \\Ot MO ( 'CO)1? Sit n drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S' Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) acks <br /> PHONE PHONE ❑Site Pla proval from <br /> appl' I township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ FI plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevatio f property <br /> PARENT PARCEL NUMBER: CURRENT ZO ING: ACREAGE: <br /> ❑PARCEL c56$ DC Si 69 L./3 ',,/ R— , /7 0-6 front e awn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> SJ{ lJ� ,/4: 1/41/4. ❑ Drive ermits <br /> C (st ,c nty,town) <br /> ADDRESS: <br /> Q‹ <br /> CSM: LOT SUBDIVISION BLOCI<OTP ary •- •• s <br /> ' IS - _r d-- (public, private) <br /> PROPOSED PROJECT INFORMATION STAF REVIEW <br /> PROJECT DESCRIPTION: <br /> ge <br /> frk--- ' Jec 0 r . S iii Z g District <br /> . ❑This project is a new building or structure. Pe • ed Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural ` •• esS <br /> F1EWER 17t EPTIC (ne e` • • <br /> HEIGHT IN FEET / NUMBE OF' F ST : (Not including basement) <br /> ' ❑ -i- •.l•'•ain/ <br /> S•• •tattachment) <br /> EA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1STFLQ ❑ Ero ••nContr• permit <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes, :• rbance, <br /> fillingligai <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3 a Q ❑ eview Location rvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ a : -vailabl!•T,.••. <br /> (Please round to nearest dollar) $ _CY ,(J <br /> /' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies e No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes a, 0 ['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? Elves 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) Elves ❑Don't know <br /> 7. Is this to correct a violation? Elves <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />