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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS NAME L <br /> ts Aryl • e'\'') °t S ❑ Zoning Status;CUP; <br /> ow/�+EE' ADD ESS ( um eer,St eecity,State,Zip) �'7 c� Deed Restriction;CSM <br /> l� I� `1 Y 1°� �ddd � �� l I / Variance(# ) <br /> HOME P ONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> ANT NA E C N CTQ E <br /> VAD‘D U 4 �Y 0/1 S 1 P \ \ S ' ��C r ❑ Site Plan including location <br /> E SS v C TO ADDRES h of well/septic <br /> °col Q��'- , � oY;? �/r. �:�e ��5 <br /> V\Ab,t, te,zip) (City,State,Z p ❑ Setbacks <br /> 46W1 U_ 53?1 t` vcro.A01, L .f)13 <br /> PHONE PHON (� ❑ Site Plan approval from <br /> Gcz �k QQQ (606) v�7 (Jc) applicable township: <br /> E-MAIL ADDRESS E-MAIlv ADDRESS , 1 <br /> �!∎k-N\Si'vISYQY 1 , co w, ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • 1/: 1/1/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: C^ `� 4 ,g < <br /> . ❑This project is a new building or structure. / _ '-'fr <br /> LI This project is an addition/alteration to an existing building or structure. i. , , <br /> SANITARY SERVICE: PERMIT NUMBER: m e s - r <br /> ❑SEWER ❑SEPTIC ',AP a 7Y-:.;-. <br /> HEIGHT IN FEET: / 1 NUMBER OF STORIES: (Not including basement) t , <br /> AREA TO NEAREST SQUARE FOOT: w r� � <br /> „..4 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) � � <br /> s �� 4 A ` <br /> BASEMENT: 1ST FLOOR: <br /> 1, TOTAL SQUARE FOOTAGE: j ;I zzf' ", ,,- <br /> . <br /> 2ND FLOOR: 3RD FLOOR � w <br /> ESTIMATED CONSTRUCTION COST: -► .4 f i � <br /> (Please round to nearest dollar) r <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? ❑Yes ❑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? LI 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 /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />