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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 <br /> 7-n!(J j- Qt t 0,5C%?�7 1�/ e m P'v./r4Q o ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,zip//)/ Deed Restriction; CSM <br /> 7 0 (9 Z L- t o �� U a Ge �� k (A)1 5.> >S 5 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 608.592 3$17 rD$ 'J 12 pe�/ ✓'us p0:4-/v),10/0cp0:4-p0:4-/v),10/0, � �C ?"frLr, c"n ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑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 /> applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: frontage drawn to scale. <br /> ❑PARCEL G;s21�ra 90 -102 —9760—6 A A 3< (i <br /> NUMBER SECTION: /o'-? <br /> TOWNSHIP: 1 El Driveway permits <br /> ba ii e 5 it, 4• iv GO �`' (state, county, town) <br /> ADDRESS: <br /> • '-70 6 '2-- Lee 2crt ( Co CC( WI 53555 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: • <br /> / n"5h b 'cL / ❑ Zoning District <br /> • ['This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rural Address <br /> FIEWER EPTIC (new/existing) <br /> !-1Vtkt'10c,u,7 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ❑ Wetland/Floodplain) <br /> a Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r--, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: disturbance, <br /> "/ \/'� I (t Deck= <br /> 4, TOTAL SQUARE FOOTAGE: 4. (slopes, <br /> C1 X ( IL- filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 120 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --0. —p -► -► -► -► $ 000 .00 <br /> and available options. <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 E]No ❑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? Yes {JNo <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# ) <br /> (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [fres (No ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ ♦ —► <br /> REV(01/19) <br />