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!' -'e <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> CUSTOMER TO PROVIDE <br /> OWNER NAME �[ <br /> Oo tc4Cl `Z'1b Lfrt"4 I4 el. 1 AZoning Status; CUP; <br /> OWNER AD DRESS (Number,Street.City.State,Zip) Deed Restric oft M <br /> `1 i" {w`l tct ca.omGifa. • 1.".;1 `D 35 X o variance(# 3�� ) • <br /> (JiQ�y(�PHONE �L,PHH•NE E-MAIL ADDRESS <br /> �(Ja� 7 • –zoo : d✓O -)55v , Site Plan drawn to scale t ",cwi <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions 6 1L <br /> AGENT NAK CONTRACTOR NMI._ <br /> 1Y1-Q.1 .(() `hc , MM e ' fl-)C. X Site Plan including location V <br /> AGE ill l•ESS CONTR TO A DRESS of well/septic <br /> ateci <br /> (city, e.Zip) (C ate,Zip) �– if'l Setbacks <br /> ,U�� U ,t yf� � ��►�-1,� iW► �3�h onc�sn�l <br /> Pt.0° Z3 P NE\336.33)O b;cot\�y ti; X Site Plan approval from <br /> :� IC J\ 1 ` applicable township. <br /> E-MAIL AD RESS E-MAIL ADDRESS is -ter <br /> 7 Floor plans to scale <br /> 41` <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: URREN ZOG:� ACkE GE Elevation of property <br /> R <br /> [k <br /> PARCEL C80/ ~0?2.4 V t ,$?� frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTI N. SeLlvh $ 150''^ kGo1 <br /> 012, IA: NW 1/ :12cr 2;1 Driveway permits jsei"en <br /> • 1 . L= ''►— (state,county,town) <br /> t ADDRESS. <br /> q5/ Ht l4 ///a ZO/hai/2-, V <br /> ll 5-351/0 )(Sanitary permits <br /> CSM: I <br /> LOT I S!BDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> t5Ui1d G 3(1 IW O $j)- l ❑ Zoning District A 2L <br /> ad <br /> - This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. t <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address A e Ai <br /> twit ❑SEWER I SEPTIC 5-) (new/existing) ��I <br /> HEIGHT IN FEET: NUMBER OF O IES: (Not including basement) <br /> one. (/) ❑ Wetland/Floodplain/ <br /> Shoreland (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 /> ErosionControl permit <br /> /1/1/0 GQ /^� 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> n/� O 7 T� filling/access) • <br /> 2ND FLOOR: 3RD FLOOR: <br /> npl Afq /9W' 694 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: f p,,,,,r)CO and available options. <br /> (Please round to nearest dollar) "♦ --► ♦ -► ♦ $ /(N <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 XNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? XYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ;$No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# el 475 (leave blank if none) <br /> 6. Is a location survey required? (see reverse) NiYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 25,No <br /> APPLICATION MUST E SIGNi="• <br /> (Continue on Back) —► -P <br /> 545-112(4'08) <br /> / <br />