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ZONNG PERM'APPUCATION wwvicoulyofdare.corn 11VuJ,a;,ta•�it•�,ra•�_�r•�:� <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> owt(Tt NAME <br /> O 6R ADDRESS (N ,street City,State,Zip) ❑Zoning Status; CUP; <br /> l 1� cI e(�0Od 13 _, St( �jh WI 5-8 ”" weed Rees#coon;CSM <br /> ItIM E PHONE C PHONE E ILADDRE ( ) <br /> V a-1 errooGi 1 C a ' 1 ►'t ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME 'CON7CTOR NAME r,, �1 0�CV1 <br /> pl, w V i. ❑Site Plan including location <br /> AGENT ADDRESS CO CTOR DRESS 6v f of well/septic <br /> a w ovds VI ipv `/Ir. (-/ <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Sty 14 , W 1 <br /> PHONE PHONE ,r El Site Plan approval from <br /> �—! _0.34.4 applicable township. <br /> E MAILADDRESS E-MAIL ADDRESS //-- 5 ®et a.L or-. ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT NING: ACREAGE <br /> I=1 PARCEL /►Y� S)l_/.�)-0L/33_,Ei ,_Z , L1 3 frontage drawn to scale. <br /> NUMBER V� O <br /> TOWNSHIP: SECTION: 1 -1 13f 12 (l& <br /> bon k,1 r�. 1/4: J Mt: ❑Driveway permits <br /> ADDRESS: 1 tier LA)oo p( e s GS (state,county,town) <br /> 1 Ca.5 n161 0dt br Lot (3 gioc k K <br /> C LOT SUBDMSION BLOCK/LOT El Sanitary permits <br /> `5 j i j (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> e&K MEM 'a.) x ON ❑ Zoning District <br /> . OThis project is a new building or structure. ,1 0 Permitted Use? <br /> Jthis project is an addition/alteration to an existing building,or structure` N <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> [)EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> l ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT 1ST FLOOR: <br /> 4 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 6y ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ _ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ Sj CZ TO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [lo DIDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Des o Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yesio <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des alp <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) Des Ft )on't know <br /> 7. Is this to correct a violation? Des <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -► <br /> 51i117/MM1R1 <br />