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ZONING PERIVIT APPlJCA11ON wuwkoou tyofda ecom <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA E <br /> ri /1 ` Fc k,-\ ❑Zoning Status; Cu ; <br /> OWNER ADDRESS (Number,S eet,City,St te,Zip r <br /> S-7 S' g of /1 Rd D e tv T t,(0- S 3a- <br /> Deed Variance Res( IC ; CSM ) <br /> HOME PHONE CELL PHONE E-MAI ADDRESS <br /> .0$-$ Sf$ 606`Nii '7°@ ., ' i iN l J' - ;IP -' s a1' g 60%n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTC•R INFORMATION and includes dimensions <br /> AGENT NAME n CONTRACTOR NAME <br /> 1� Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks I <br /> ' <br /> PHONE PHONE ❑Site Phip 4�pPi+-'oval from <br /> applicdtmwnship. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑Floor plan 4) <br /> PROPERTY/LOCATI cip FORMATION '(Jittp://accessdane.co.dane.wi.usI}- ------- ❑Elevation f r- • <br /> PARENT PART �1BER: CURRENT ZONING: ACREAGE: ��.a' 4 <br /> ❑PARCEL Ma 914n(12r2 a 1 V�/ frontage draw.f�Pcale. <br /> NUMBER l/ �'ll1'liJ /`�'j G' ll <br /> TOWNSHIP: SECTION: �/ <br /> • t�j } '/<%4: ❑Driveway ; its <br /> ADDRESS: (state,cah %, :" n) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sani(pub Vptis 'C/ <br /> POSED PROJECT INFORMATION STAFF REVIEW <br /> ]r' JECT DESCRIPTION: <br /> Co� cif "411\5 n(2.4.0 9rd 6 OD7of bin ❑ Zoning District <br /> . iiiihis project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> S Y SERVICE: PERMIT NUMBER: L3 Rural Address <br /> W <br /> EER SEPTIC (new/existing) <br /> tbx i N FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionControf permit <br /> BASEMENT 1ST FLOOR:L _(����/^iq I <br /> ♦ TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: l b CI I <br /> 1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> ♦ ♦ ♦ ♦ ♦ ♦ <br /> (Please round to nearest dollar) r0(�'�� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des "lo DJon't know <br /> 2. Is there a wetland or floodplain on or near the property? es .,ii► • EThon't know <br /> 3. Have you talked with the township about your project and are they in agreement? es • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es iaio <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 4174 o don't know <br /> 7. Is this to correct a violation? ❑Yes 117 o <br /> �/� (� /�I I/� APPLICATION MUST BE SIGNED <br /> °,' 1 y\ V y c/. I � �/J (continue on Back) <br /> saw„ rcmn� N 1 <br /> P17-7777 <br />