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:SUPPLEMENT to Web=App`#;' <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME <br /> iltlA )((DNCT Li Zoning District <br /> OWNER ADDRESS (1\l amber,Street,City,State,Zip) n ,Q f , <br /> 5)17 S I�Ie �1pi'Q,tl 17'' l 'kokciL5 , wT 5 3) I V ❑ Permitted Use? <br /> PHONE E-MAIL ADDRESS / <br /> 22-2— 3 , ' • 170 KI Cif`)C-1- @ C"'"1"'/• "e+ ❑ Zoning Status; CUP; <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restriction; CSM <br /> AGENT NAME CONTRACTOR NAME <br /> Variance (# ) <br /> OIJ N•-r- <br /> AGENTADDRESS CONTRACTOR ADDRESS ] Site Plan drawn to scale <br /> and includes dimensions <br /> (City,State,Zip) (City,State,Zip) <br /> Site Plan including location <br /> PHONE PHONE of well/septic <br /> E-MAIL ADDRESS E-MAIL ADDRESS Setbacks <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.wl.us/) ;;,:- ❑ Site Plan approval from <br /> PARENT PARCEL NUMBER: ZONING: ACREAGE: <br /> Li PARCEL applicable township. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ❑ <br /> a �yp 6r ✓-Q- 2(, Y4: A) E 'WA: 5 Rural Address <br /> (new/existing) <br /> ADDRESS: <br /> X96t1 ��p <br /> 7 /Or r`�1 ❑ Floor plans to scale <br /> CSM: LOT i SUBDIVISION BLOCK/LOT <br /> 987, - ❑ Elevation of property <br /> PROPOSED PROJECT INFORMATION • -fir frontage drawn to scale. <br /> PROJECT DESCRIPTION• � / � <br /> C k Ras, e� a ❑ Driveway permits <br /> This project is a new building or structure. (state, county, town) <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> ❑ Sanitary permits <br /> SANITARY SERVICE: PERMIT NUMBF,$:w 6,/ <br /> ❑SEWER SEPTIC c / `'`} (public, private) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ❑ Wetland/Floodplain/ <br /> 020 / Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: - <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) n-..1Erosion Control permit <br /> BASEMENT: 1ST FLOOR: <br /> ,l TOTAL SQUARE FOOTAGE: 4, (Slopes, disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: z 7 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: d� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ --0 ♦ •p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? N Yes ❑No ❑Don't know <br /> 2. There is a wetland or floodplain on or near the property? ❑Yes S No ❑Don't know <br /> 3. Have you talked with the township about your project? N Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 0 No <br /> 5. This project is associated with a rezone/CUP/variance (petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? 14Yes ❑No Li Don't know <br /> 7. Is this correcting a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i --►: <br /> 545-112(1/08) <br />