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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA <br /> --)a-50ii CrticS 8YtLtbe I .2-r✓ oning Status; CUP; <br /> OWNER ADDRESS'(Number,Street.City,State.Z Deed Restriction; CSM <br /> CS r^6.2- '` Sit c.r`C O1/ Wi 3-3 — Variance(# ) <br /> HOME PHONE CELL PHONE E iA L A DRESS <br /> Of - 7!, — asa. . br.be^d e,—a idr,Ps a').ca/•. Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT N A i' CON 'ACTOR NAME / <br /> Ad A .. cf,1-,S a �, ea g4ite Plan including location <br /> AGE •*DRESS CONTRA'i-AD E S of well/septic �( hgct <br /> G rn 0_ ' qv ' 61-1. Ste-/2-- ;,-N'tc- <br /> (Ci ,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE Kr-01)+e /4a E VO Site Plan approval from <br /> !_ <br /> ,f.__i2e ''7 j7CP applicable township.y <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Ma;) a Ga `-frd,•oud , Lom Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) -Elevation of property N� <br /> ❑ <br /> PARENT PARCEL d 2 Y 25z 0 EN ON2 ACREAGE: � <br /> PARCEL ((TT�1 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP S <br /> VtA n 1/4: .7E %I/4. d''-"veway permits A <br /> ADDRESS (state,county,town) <br /> )Pe g .a-..• //4-1:'' i anit_• permits <br /> SM LOT i BDIVISION BLOCK/LOT <br /> N .Ublic, •rivate) <br /> I i <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION' <br /> .�r-'")r0(,t.VII PCB - onrng District <br /> .. %This project is a new building or structure. rrnitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVIC , PERMIT NUMBER 0 Rural Address <br /> EWER FIEPTIC (rtew/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) y ✓'; 5• <br /> `hor- and A,attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> rOSiOnCOntrOi permit <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR 3RD FLOOR: 1-� <br /> filling/access) <br /> 1 ��rievv Location Survey <br /> ESTIMATED CONSTRUCTION COST: :7 ? and'available options, <br /> (Please round to nearest dollar) -4 -, ♦ ♦ ♦ ♦ $$ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? s /No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 10No <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 -131No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,EINo <br /> i, APPLICATION MUST BE SIGNED <br /> (Continue on Back) -s -+ -► <br /> 545-112(4/08) <br />