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. I0g1 <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O R AMME,, /I Kx 4- i�''7 X Zoning Status; CUP; <br /> O ER ADDRESS (Nu sheet.City,star Deed Restriction; CSM <br /> 3q L P�/�°(DUn4�S V"—� �1��- Variance(# ) <br /> HOME PHONE ELL PHONE E-MAIL DDRE <br /> / —� ►' ine <br /> ,0$161-3I stS93-- 90—' a pp Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ,NiSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Ian approval from <br /> ap icable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loo laps to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ►■ eva n of property <br /> PARENT PARCEL NUMBER: CURRENT ZONI : ACRE GE: P P y <br /> PARCEL (R� Q/�d/� (� 1 �'i fro ge drawn to scale. <br /> NUMBER �� O/ _ I -1 I WPU^ 1 a� �O �, <br /> TOWNSHIP: tv SECTION: �q l^Qrtc� co El-ow-1'1r 7� <br /> U�Vvi01'14-- 1/4: 1/41/4: Drivewa ermits <br /> AD Ess: (state ounty,town) <br /> �r✓3 n 24 (?(ueN( hds l„Z3. 57.-P <br /> CSM: LOT SUBDIVISION BLOCK/LOT ,- Sanitary permits <br /> (public - .,- e. <br /> PROPOSED PROJECT INFORMATION - <br /> STAFIF REVIEW <br /> PROJECT DESCRIPTION: <br /> r_ ^Zoning District <br /> . ❑This project is a new buil mg or structure. ` <br /> KRerrnrtted Use? <br /> 9fhis project is an addition/alteration to an existing building or structure. <br /> t uraLA dress <br /> SANITARY SERVICE: �/a„ PERMIT NUMBER: ""' <br /> Li SEWER LI SEPTIC ne ` <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ' <br /> r`etian®I"t.sap : A," c <br /> Shoreland (attach `° t)L ,.\ <br /> AREA TO NEAREST SQUARE FOOT: ... , 1'f3, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR ❑ ETs: . _. r. • it <br /> Li ,, TOTAL SQUARE FOOTAGE: ,, (S.pes,disturban•-, <br /> - <br /> 2ND FLOOR: 3RD FLOOR: v sL� fill - -cc- • ) <br /> I eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: ,\ <br /> (Please round to nearest dollar) _, ..+ ..+ ♦ 5 U Q b and availableOptians <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 1! s ❑No ❑Don't know <br /> 2. Is there a wetland or floodpldin on or near the property? ( i'<'es ❑No Cl Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 2eYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? O❑Yes lo <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 UKo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes &No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />