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DM NG PERIVIT JCATICN vwwkoourttyofdane.vorn SUPPLE A4 ENT t o Web App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE 4
<br /> OWNER NAME
<br /> Re X ? Ly�7 cite_ U cu e IS oning Status;CUP; /
<br /> OWNER ADDRESS (Nurr&r,Street,City,State,Zip) Deed Restriction;CSM 9 / 23
<br /> /8 3 q Sfafe Roet d /9 Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> O5-5/3-/9S re o weiS9 q 4 • - t t z0 Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions /p 0
<br /> AGENT NAME CONTRACTOR NAME /
<br /> 51e tie Stec-Mr- e h,„„.,p,„., of Haul1 ,, g Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS Rd' of well/septic
<br /> Sa:0-1 e.- 2 53 1 lid 5.e.3
<br /> (City,State,Zip) (City,State,Zip), Setbacks /0 Vii 6 004/
<br /> -)a br.,t, /la or os-► 53 7 fe 50
<br /> PHONE PHONE tWite Plan approval from
<br /> So Art 608-E.P)-,8 G ZOO applicable township.
<br /> E-MAIL ADDRESS E-MAILADDRESS 1
<br /> 5, r1-7 .s 4 tter—,V , fi ,as,.,, ca. ivy Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (hitp://accessdane.co.dane.wi.us/) �Elevationof property
<br /> PARENT PARCEL NUMBER: CURRENJr�ONING: ACREAGE: P P rty
<br /> ❑PARCEL / pp_'�3 _y6 1,--z-
<br /> NUMBER /� — ! �i4/T frontage drawn to scale
<br /> , ` 7/ t
<br /> TOWNSHIP: SECTION:
<br /> Svi✓l Pr a i r 1 e I Z I'J(A) '/.: 3 t-t) %%: .0 ay permits
<br /> ADDRESS: / tat ounty,town)
<br /> 0 3 if Slate,, Ko a d /g , Sanitary •-_...is
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> 8 ct$o S r___.__ r (publi ,pr vat
<br /> PROPOSED PROJECT INFORMATION R ° STAFF REVIEW,
<br /> PROJECT DESCRIPTION: �'�4t r4
<br /> [ ;j a Cl�aPn p•e 3 aScs-r 5cen r coo r..-1 Zoning©is ict
<br /> ❑This project is a new building or structure. �,
<br /> 'Permitted tlse?
<br /> This project is an addition/alteration to an existing building or structure. �', ?��.
<br /> SANITARY SERVICE: PERMIT NUMBER: z X Alga V�, ;,.1, ,„,-. 0
<br /> r1ew ISU
<br /> EWEREPTIC �.
<br /> HEIGHT IN FEET: YYYYYY °°^°°^ NUMBER OF STORIES: (Not including basement)
<br /> ` � � Xrr
<br /> / ' �t• a /�
<br /> // AREA TO NEAREST SQUARE FOOT: har and k ',7 /b`V}-
<br /> S SQU 00 �mw. - ,
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , = Wr
<br /> ( 9 9 9 9 p ) ►, -Eros OnCGntrOl
<br /> BASEMENT: 1ST FLOOR:
<br /> ! TOTAL SQUARE FOOTAGE: I (slo es,disc`r ance•'
<br /> •2ND FLOOR: 3RD FLOOR: ffllitla a y r
<br /> ' � srr a
<br /> /1/3 d vi :o� ur e
<br /> ' A--
<br /> ESTIMATEDCONSTRUCTION COST: r 737 # I • e •,,
<br /> (Please round to nearest dollar) � � n.
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [lies 'lo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 'lo `®Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? BYes Elo
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ao
<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 o ['Don't know
<br /> 7. Is this to correct a violation? [Yes o
<br /> • ICATION MUST BE SIGNED
<br /> 545-112(4/08) 6 , ,, ,y (Con •ue on Back)
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