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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> ^, <br /> 1 �- 0)l� L�/) (h t... 1.--- ...R R r . Zoning Status; CUP; <br /> OWNER ADDRESS` Number,Street,City,State,Zip) 'Int• t1LC3 Cv t ed Restriction; CSM <br /> 6 9 q C C;t,�;.--t`--A1.,' N-° t k. ,.--,36-- 5 j.� 7 - riance(# ) <br /> tiergi �W1ONE CELL PHONE W��it e_. E-MAIL ADDRESS <br /> �` (('L,! -22...c3- �15� �'%- ; c _ c- r 0 � -�.�AZ it Ct i , k ©/Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite Plan including location <br /> A-GENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE 1:1S. e Plan approval from !� <br /> PHONE :i7licable township. <br /> E-MAIL ADDRESS E-MAILADDRESS cI <br /> IN loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpi//accessdane.co.dane.wl.us/) Elevation of property <br /> PARENT PARCEL NUMBER; CURRENT ZONING ACR Efrontage drawn,to scale. <br /> 0 PARCELUMBER I ^ C)-7 1ZZ-a 7 f,% <br /> TOWNSHIP: SECTIO : privewpermits <br /> l/4.S V~ 1�4. <br /> e <br /> .+ t% (stag', county,town) <br /> '-[ q C t 1c.1,A. Rocky `til V i\,\..-i- . I-4 6k t .5357 ❑ Sanitaryrpe its <br /> CSM: OT SUBDIVISION BLOCK/LOT (public`, private) �,� <br /> 1 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DE RIPTION: � r 6Z 0 —. <br /> 0.-CXg�"`k C�Ce.�1�C�.-�-� (`'�J n U Zoning District <br /> Z1,This project is a new building or structure. J Permitted Use? <br /> This project is an addition alteration to an existing building r cru ture. <br /> SANITARY SERVICE: 11 PERMIT NUMBER: y� <br /> LI Rural Address <br /> EWER rqEPTIC (ASI (newle7)Sting), <br /> HEIGHT IN FEET. 1? / NUMBER OF.STORIES: (isl including basement) <br /> D Wetland/Floodplain/ <br /> Shareland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ErosionGontCQipermit <br /> BASEMENT: 1ST FLOOR: /` , , e <br /> (\S�j J(V, j TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: , <br /> 0 0 ,'' <br /> �� J Review Location Survey ,t <br /> ESTIMATED CONSTRUCTION COST: r� and available options. ' \-'`-- <br /> (Please round to nearest dollar) ..+ -+ -* --► -► ♦ $ ,,/J`o / 0 0 <br /> l <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dees vtjAJo ]Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes ( No []Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ❑No M.`(--O t--. <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? []Yes f2-4No v--e- <br /> ci <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) QYes glo ❑Don't know <br /> 7. Is this to correct a violation? ]Yes [Salo <br /> 41 i(C) . ----- APPLICATION MUST BE SIGNED <br /> (Continue on Back) -, -o. —. <br /> REV(01/19) <br />