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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION uwuw.countyofdane•com <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME n <br /> `� f � G c y '.S )�C)1l-� 0 Bon n District <br /> OWN-- -••=- SS (Number,Stre' ,City,S ate,Zip) <br /> • /Q 6 /6 g Cl Permitted Uses <br /> pH,. E-MAIL ADDRESS , <br /> 2 / — a Zoning Status,CUP, <br /> AGENT INFORMATION CONTRACTOR INFORMA?ION peed Restriction CSM <br /> AGENT NAME CONTRACTOR NAME . Variance'(# ' <br /> �. <br /> o`Q-r Q it 1 <br /> AGENT ADDRESS CON RACTOR DDRES D I ET Pl'- drawnngto ace's <br /> fp L �d c1 e,�� and Includes dimensions <br /> (City,State,Zip) (City e,Zip) <br /> yy�� z n <br /> rod 4(IT/iN ACC/J Si v-3 D Site Plan including"location: <br /> PHONE PHONE / J ofwelUSt tic <br /> 5'21 - 97 `z' <br /> E-MAIL ADDRESS E-MAIL ADDRESS Setbacks <br /> PROPERTY/LOCATION INFORMATION (httpa/aceessdane.co.dane.Wl•us!) 0 Site Plan approval from k <br /> PARENT PARCEL NUMBER: ZONING applicable township. <br /> U NUMBER , 3 "' 1'� a - r — kfA , <br /> TOWNSHIP: SECTION: IiIraFAddiGsgg <br /> iA 1 ♦ I C t <br /> '/a: /a/4. ewtexisti f,# <br /> ADDRESS: e / 1A/j:. ' <br /> r . (7-o ry RA i 'd'- y r' Tan/ Floor plans t sc le l <br /> SUBDIVISIO' BLOCK/LOT Z:, ;� <br /> CSM: s� LOT r• <br /> 1 . d. .` <br /> PROPOSED PROJECT INFORMATION "°`' t, , '�� . <br /> PROJECT DESCRIPTION: is i , +v v ♦ a a <br /> ,� l' x 3(7 ri t <br /> 1 � i • � �, <br /> L This project is a new building or structure. �' - I <br /> ❑This project is an addition/alteration to an existing building or structure' Sa itaty permits <br /> SANITARY SERVICE: PERMIT NUMBER: ublc,p e €1 � <br /> ❑SEWER N SEPTIC <br /> NUMBER OF STORIES: (Not including ernent) i_ Wetland/Floodplaln <br /> HEIGHT IN FEET: V <br /> /' f 1 / Shoreland (attachment) ' <br /> AREA TO NEAREST SQUARE FOOT: s or porches <br /> (Outside dimensions including unfinished area,attached garages and above grad ) ErostonCortrol permit <br /> BASEMENT: 1ST FLOOR: ARE FOOTAGE l (Slopes,disturbance, <br /> j, TOTAL SQU, filling/access <br /> 2ND FLOOR: 3RD FLOOR: <br /> Zal° „ „, <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options <br /> (Please round to nearest dollar) --► <br /> 1. The property isl within 300 feet of a stream or 1000 feet from a pond or lakes Yes ❑No ❑Don't know <br /> xi Yes ❑No ❑Don't know <br /> 2. There is a wetland or floodplain on or near the property?. ..................................................... Yes ❑No <br /> 3. Have ou talked with the township about your project. <br /> you P Y P 1 ears• ❑Yes PA No <br /> 4. Has there been a zoning permit issued for this property in the past 5 y <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal#�— <br /> (leave blank if none) <br /> ❑Yes f1 No ❑Don't know <br /> 6. Is a location survey required?....................................................................... ❑Yes r� <br /> 1&+No <br /> 7. Is this correcting a violation? <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -♦ <br /> 545-112(1/08) <br /> ,'s,. <br /> h <br />