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p.64 . ® SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdine.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1 <br /> G-� Lo^a` 1-10A) • I-1--C ❑ Zoning Statu ; UP; <br /> OWNER ADDR SS (Number,Street,City,Stat p) <br /> 19-1 I N,0 51 S1-0 L- \ 53,5 ti Deed Re ction; CSM <br /> Variance(# ) <br /> HOME PHONE tJ CELL PHONE E-MAIL ADDRESS <br /> 0g'9,3' L L '.J bflY'5 0� 1 r,� iv )4- • At.e\ r,(,y1 ❑ Site Plan dra o scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and inclu dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ghc L orc k ❑ Site PIN 0 ding location <br /> AGENT ADDRESS CONTRACTOR-AADDRESS of wel(/s <br /> /y7/ y-,1 .51 _�(�� <br /> (City,State,Zip) (City,State,Zip) _ _ ❑ Setb Go c ,1 in\ <br /> PHONE PHONE J��U� �� �35 El Site Pl9ip / al from g -. yL/p 7 appli hip. <br /> E-MAIL ADDRESS E-MAIL D DRS/^ D <br /> 10 14p ` tr, c.ti,.,44-co❑ Floor plrto scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of p perty <br /> PARENT PARCEL NUMBER: 'lour( TZONING: ACREAGE: <br /> ❑ PARCEL O b 0 °C ( — / � frontage r n to scale. <br /> NUMBER 1 L/ <br /> TOWNSHIP: ((�� SECTION: ,/a: .�a1�a: ❑ Driv r • s <br /> rlv`�l (st e, n y,town) <br /> ADDRESS: 'I// n <br /> i fsi 00-14 PQ N I SU C El Sani : •-Al it <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (pub' • '- -) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT ASCRIPTION: REVIEW <br /> rite-s1 t 1�rnr 0v� 0 Zoning ttict <br /> . SI This project is a new building or structure. <br /> El This project is an addition/alteration to an existing building or structure. f <br /> SANITARY SERVICE: PERMIT NUMBER: © Rura 4 reSS. <br /> (SEWER SEPTIC done. (q 1 I ° , am' <br /> n, <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I <br /> Id r <br /> Cl we! °ma � <br /> AREA TO NEAREST SQUARE FOOT: ` �� <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ' <br /> BASEME T: I 1ST FLOOR: <br /> 1 .t'�QI'I • • ) i <br /> ,,�C \ + 4 TOTAL SQUARE FOOTAGE: 4 (slopes,'" , • x <br /> 2ND FLOG 3RD FIrOOR: <br /> Qur1 ; 5 4o'X 1`6 t7 7 2009i /O 8O D <br /> ESTIMATED lease r CONSTRUCTIllar)COST: ♦ ♦ ♦ ♦ -► ♦ $ rya 3 00 an ,° 0\i{i 4. <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 S No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? El Yes E No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ®Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? *I Yes El 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 El Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/0 / j '��O 4,14 (Co ti` n�ue on Back) ♦ ` <br />