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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS ME <br /> a {SSe ❑ Zoning atus;CUP; <br /> OWNER ADDRESS (Number,Street,Cit tale„Zip) Deed Res • tion;CSM <br /> at,D,.3 )? y 't!a t \ eiOf ■ 1. 535T93 Variance(# ) <br /> HO,E PHONE CELL PHONE E-MAIL ADDRESS <br /> 4 Tiis- 9416% / Site drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and inclu es dimensions <br /> AGENT NAME CONTRACTOR NAME (01‘54. <br /> 9 film tOf'�t `&cs+. LI_C MM RO LL Site Plan including location <br /> • K AGENT ADDRESS ,,pp n� CONTRACTOR DDRESS of well/septic <br /> `� 03O RI lit,' Ig 0030 /2tJlr X29. . <br /> (city,State,zip)1 (City,State,zip) <br /> "(Setbacks <br /> �AuY � W 1 5365.1 (-)GAKAaV- <br /> ()A s3S-57 <br /> t` PHON P ONE _) ❑ Site Plan approval from <br /> S (GOS) 3S-0 5151 �(00�) --S-4f7- S lsl applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor pla to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elev ion of property <br /> ❑ PARCEL (...%0.,,e2 Q/ fronts drawn to scale. <br /> NUMBER (o� ”b/0 i <br /> TOWNSHIP: SECTION: <br /> Y4: '/a'/a: ❑ Drive ay permits <br /> ADDRESS: (state,c nty,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanita permits <br /> (public,p 'vate) <br /> PROPOSED PROJECT INFORMATION '`" -.' <br /> PROJECT DESCRIPTION: f <br /> 3- <br /> ' �( �(o �gYC1e�� <br /> This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. "`^ <br /> e:.+ .- <br /> SANITARY SERVICE: PERMIT NUMBER: w s <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) g` <br /> /7 r— / T2 MI ae e &: so <br /> AREA TO NEAREST SQUARE FOOT: 7M ,$ <br /> (Outside dimensions including unfinished -.,attaci3gtiegkrrages. nd above grade decks or porches) <br /> BASEMENT: 1S OOR: p/ / ® w .:,,=.1 <br /> i a )/ LSD ,, TOTA Q •RE FOOTAGE 4, ,.+ ,�° °' <br /> 2ND FLOOR: C RD FLOOR: ���' _ * ° ,j' <br /> - ' ` v ` w <br /> ESTIMATED CONSTRUCTION COST: q o ;� a'.0 54, <br /> (Please round to nearest dollar) -► ♦ .-► .-► ♦ -► (/. �dio it at ,-` <br /> I •�� " ate„ ate ,. <br /> r---1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes CZ No ❑Don't know <br /> . 2. Is there a wetland or floodplain on or near the property? ❑Yes Dil.No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? )151Yes ❑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# ) (leave blank if none) <br /> �- 6. Is a location survey required? (see reverse) ❑Yes ❑No Don't know <br /> 7. Is this to correct a violation? ❑Yes p No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aios) (Continue on Back) —► —► <br />