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• SUPPLEMENT to Web-App It <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME <br /> Gf Y -4 D IIME RU PPERT Zoning District <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 17110 CD V MTy Hoye PP i VEPCAI R, 0 1 L.6.3,53 geermitted Use? <br /> PHONE E-MAIL ADDRESS -� <br /> &10v — F 613 • rt) ' P rr rf-4-0 ""s' %��J > <br /> zoning Status; CUP; <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restriction; CSM <br /> AGENT NAME CONTRACTOR NAME Variance(# ) <br /> D 0 N 1,-V61( <br /> AGENT ADDRESS CONTRACTOR ADDRESS Site Plan drawn to scale <br /> and includes dimensions <br /> (City,State,Zip) (City,State,Zip) 1 <br /> g L L E it I c L-6 W ( ). Site Plan including location <br /> PHONE PHONE of well/septic <br /> 601 - `11 �- 3o1I <br /> E-MAIL ADDRESS E-MAIL ADDRESS V Setbacks <br /> PROPERTY/LOCATION INFORMATION (http://accessdano.co.clane.wLus/) . I il Site Plan approval from <br /> PARENT PARCEL NUMBER: ZONING: ACREAGE. applicable township. <br /> ❑ <br /> PARCEL NUMBER 06210 b08-35y-Nio-i{ R it l <br /> TOWNSHIP: SECTION: Ural Address <br /> O(o VERb NA 35 '/4: s '/4'/.: N� (ne existm .. <br /> ADDRESS: ^----in <br /> 171(p ,Q U NT.Y HIP"' P8 -afloor plans to scale <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> Elevation of property <br /> PROPOSED PROJECT INFORMATION frontage drawn to scale. <br /> PROJECT DESCRIPTION: <br /> DE ,I- Li Driveway emits <br /> . ❑This project is a new building or structure. (state ounty,town) <br /> This project is an addition/alteration to an existing building or structure. ❑ Sanitar ermits <br /> SANITARY SERVICE: PERMIT NUMBER: (publ}c private) <br /> ❑SEWER SEPTIC / <br /> HEIGHT IN FEET: ` NUMBER OF STORIES: (Not including basement) ❑ Wetland/F odplain/ <br /> r5 1 Shorelarfd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) [] ErosionCon 'ol permit <br /> BASEMENT: 1ST FLOOR: SIO P eS, ' turbance, <br /> TS--- _�a� <br /> 1.5 O D 1.5 I�6 TOTAL SQUARE FOOTAGE: j, filling/a cess) <br /> 2ND FLOOR: 3RD FLOOR: ©6 D <br /> 1.4'Review;eeation Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 3 I 500 . 66 and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ES No LI Don't know <br /> 2. There is 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? .1Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes iNo <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal# ) <br /> (leave blank if none) <br /> 6. Is a location survey required? ❑Yes 'No ❑Don't know <br /> 7. Is this correcting a violation? ❑Yes .211\10 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -► -+ <br /> 545-112(1/08) <br />