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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 /> -07CAn• rLL <br /> 5 't 6--ee, 1 )Ot ®Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,'City,State,Zip) Deed Restriction; CSM <br /> 5 $WI `,tqck 0 C x v ei PICA2=1 I 56t, 11-1. Variance(# ) /` <br /> HOME PHONE CELL PHONE ' E-MAIL ADDRESS <br /> '&I) * a 2-05 r *4 :our_ . IAA;* t ., el- pi Site Plan drawn to scale f'' <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions,,' <br /> AGENT NAME CONTRACTOR ME <br /> I S .3 D _`__ .' `d-e i 5-�► 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 646 " Cie <br /> (City,State,Zip) (City,State,Zip) 153 Setbacks <br /> MU.rs 14...0 tf4 c3.5-5-1 • 0 <br /> IA Site Plan approval from <br /> PHONE( ) 2 Z G —40/1 0PHONE applicable township. <br /> E-MAIL ADDRESS o E-MAILADDRESS <br /> Crit A. ` D f f ><i %r �( 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpa//accessdane.eo.dane.wi.us/) ©Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: �r 7 frontage drawn to scale.El PARCEL <br /> NUMBER lag_ Z, �( 7 <br /> TOWNSHIP: (5i� ' ( ' ' t ` SECTION: ®Driveway permits <br /> Ve(-cry c; 1/4:MI %: l"f (state,county,town) <br /> ADDRESS: {� <br /> 1 ?Q' , 1 1 Z -C" 1 Sanitary permits <br /> CSM: LOT SU !VISION \ BLOCK/LOT (public,private) <br /> c 13 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> '1J0t (j 4) / i..-F \,J( rf•V-1't �! i10, V J Zoning District <br /> „k- <br /> . This project is a new building or structure. � U 0 Permitted Use? <br /> This project is an addition/alteration to an existing building or struc ure. <br /> SANITARY SERVICE: PERMIT NUMBER r ❑fturalAddress <br /> EWER EPTIC 13 r� c(�J — C C, c `(_� Y (new/existing) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> a- / a Wetland/Floodplain/ <br /> Shoreland (attachment) .,.k,' <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) `` <br /> LA ErosionControl permit j • <br /> BASEMENT: 1ST FLO / t �I TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, l �. <br /> •J/ �v5�(r "� 7 filling/access) 1W?"-1.- <br /> 2ND <br /> J{� <br /> 2ND FLCJOR: 3RD FLOOR: 04 -.)e-711-1� 0.0 ��ve J <br /> .) CcO,Co }�. Review Location Survey . , <br /> ESTIMATED CONSTRUCTION COST: ♦ ' ♦ ♦ $ C C) tand available options.(Please round to nearest dollar) I��JJJ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ['lo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? Oyes F2! o ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? LYes 111 o <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) as 'lo ODon't know <br /> 7. Is this to correct a violation? Dies ►� 0 <br /> L,/— APPLICATION MUST BE SIGNED <br /> C,'' ♦t�/ 7 (Continue on Back) - <br /> REV(01/19) . ;) `l- <br />