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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 e C- <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (N4mber,StrJee�tj,City,State,Zip) r/ v Deed Restriction;CSM <br /> /17-'LJ�// / 1 I M a 2 c�+^�1►�t G �' �J (r Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL AD'DRESS <br /> , S y30 dY6 rya^ c"`4 2-0e +-.,e..❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> A �. ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,state,zip (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> ii5 Al applicable township. <br /> E-MAIL ADDRESS 604.,< E-MAIL ADDRESS ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL c0 80 706 3 q VCS , `-o Q frontage drawn to scale. <br /> NUMBER / <br /> TOWNSHIP: SECTION: <br /> 6 1/a: 1/x1/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> H y Pi ' ' OJ ^A.n,C 0, 5--.,,6 C) ❑ Sanitary permits <br /> C1: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> ✓�YIENC <br /> PROJECT DESCRIPTION: 4 <br /> ���� yea ;i Z t <br /> This project is a new building or structure. 0 P a <br /> ❑This project is an addition/alteration to an existing building or structure. - , <br /> SANITARY SERVICE: PERMIT NUMBER: _ AdSS <br /> ❑SEWER ❑SEPTIC (new! t <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) = A�,,. <br /> AREA TO NEAREST SQUARE FOOT: s � B �� � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r <br /> BASEMENT: 1ST FLOOR: a a <br /> 4, TOTAL SQUARE FOOTAGE: 4, ,,,.. a(! a <br /> r' �'E a a ra °�.. <br /> 2ND FLOOR: 3RD FLOOR: 0 il *1 3" <br /> '� ew ,.�=a <br /> ESTIMATED CONSTRUCTION COST: (OLIO" s : u : ,i a', <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes -rlo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑YesNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank' none) <br /> 6. Is a location survey required? (see reverse) ❑Yes N 10 Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />