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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> -- -- ❑ Zoning Status;CUP; <br /> OIANER ADDRESS (Nu er,Street,City,State,zip) Deed Restriction;CSM <br /> ariance(# ) <br /> t-OMEPHONE CELL'HONE E-MAIL ADDRESS <br /> ,c%-a(o )/16 12- t-{ <br /> • Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT AME IFS_ A\li r% • LL C CONTRACTOR NAME <br /> dik���' �..`��\-l�il�� I ... ► kA - um '14I` VA S'a Plan including location <br /> AGEN ADDRESS CONTRACTO-A.■R SS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Plan ap al from <br /> pplic ownship: <br /> E-MAILADDRESS <br /> ( EMAILADDRESS <br /> � <br /> /Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wi.us/) E vation of property <br /> PARENT PARCEL NU BER: CURRE Z NG: ACREAGE: ^� P P rty <br /> LI PARCEL I (; I '/c coo( 0 fontae drawn to scale. <br /> NUMBER � y a ()� �I^I(�-��� -b � <br /> TOWNSHIP: SECTI N: ■ , <br /> C ‘A (by �r-ov.p _ '/a: 1/y.: R iveway permits <br /> (state,county,town) <br /> ADDRESS: t <br /> • ' a O s & t '-€-(cte.I°d f WE Sanitary permits <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT <br /> (pu•lic,private) <br /> •to <br /> PROPOSED PROJECT INFORMATION 'Y ,; <br /> PROJECT DESCRIPTION: <br /> ' <br /> *This project is a new building or structure. �-s t # .. $ g, - <br /> ❑This project is an addition/alteration to an existing building or structure. � E f <br /> SANITARY SERVICE: PERMIT NUMBER: ®' i <br /> ❑SEWER SEPTIC g 00 .' a <br /> - ' 4 <br /> ,. <br /> HEIGHT IN FEET: NUMBER OFcTORIES: (Not including basement) <br /> §F� $� saga^ St 4, a�l-" <br /> 3u t e a �. ,+ "d&, m. <br /> AREA TO NEAREST SQUARE FOOT: T ~ :. � - <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) x- b, :7,..> <br /> _ <br /> BASEMENT: 1ST FLOOR: • ,,4 $ <br /> 4, TOTAL SQUARE FOOTAGE: ,�, 4 a14-41 �= �r, <br /> 2ND FLOOR: 3RD FLOOR: �. _ � <br /> ESTIMATED CONSTRUCTION COST: 0 Oto * • _' •, <br /> (Please round to nearest dollar) , �xfr <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes B'F o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2'`Jo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? i'Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? .❑YYes ❑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) ErYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,8"No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —0. —I. -11. <br />