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ZONING PERMT APPUCA11ON vwwkcouityofd oom tar,J J,4;,I4•I ts(;-1,,n r_v;i <br /> PROPERTY OWNER INFORMATION iii-TOMER TO PROVIDE <br /> OWNER NAM ,, l <br /> a cf IR. C� ►v&)P Z ping Status; CUP; <br /> OWNER ADD SS timber,�Str/eet,City,State,Z ' I D e Restriction; CSM <br /> VSi, L�. i\Ir'R�-e_ <br /> .. E- ILADI '\ SeUI��OrJ nce(# ) <br /> HOME PHONE c" CELLI PHONE L/ A <br /> 5■ tit'. oot,'' s V 1 t' t� • Co %Plan drawn to scale <br /> AGENT INFORMATION i CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5.,1\ <br /> \ )∎ g- ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> 79 ■3 C dyv_S.\vrve i,(l <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> Si>ry\L Cji i u.'\, 53 .503 <br /> PHONE PHONE p ite Pla pproval from <br /> U - \C\ - Z\\ p le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r(h;Urc c--9b; \1 L:J e, . cen, F oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usi) <br /> PARENT PARCEL NUMBER: C RRENTZO NG: ACREAGE: .� hievation of property <br /> ❑PARCEL C 7 0,p . ,r V-P( Wo.. `1_ C r .�� frontage draw scale. <br /> NUMBER 11 NV <br /> TOWNSHIP: ' Q SECT:M I ,.iA I�� s 1/4%. "SE ❑Drivew permits <br /> ADDRESS: (st ,count own) <br /> LI�(,) 4 EU Rc IZeeIJ IZe ' ❑Sanit permits <br /> CSM: 140,„C1 LOT 1 SUBDIVISION BLOCK/LOT <br /> U u c,private)■ <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: / f <br /> 1� S # i oning District <br /> . IThis project is a new building or structure. ermitted U -? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural • •.re <br /> DEWER E.EPTIC �� (new/:xistin• <br /> HEIGHT IN FEET: O NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/F odplain/ <br /> Shore d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ EroslonContr permit <br /> `'.9:1' (7 . j TOTAL SQUARE FOOTAGE: j (slopes,d. urbance, <br /> 2ND FLOOR: 3RD FLOOR: tfilling/a ess) <br /> ❑ Review Location Surve / <br /> ESTIMATED CONSTRUCTION COST: h` and available options. �/ <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ J/ O O 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des 3,1,0 Dion't know <br /> 2. Is there a wetland or floodplain on or near the property? Des o DDon't know <br /> I (�ihlave you talked with the township about your project and are they in agreement? ❑Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des 'iVz <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> ,c)11s?'a location survey required? (see reverse) Ekes o DDon't know <br /> 7. Is this to correct a violation? Des o <br /> 90 APPLICATION MUST BE SIGNED <br /> �•_..^ •MO �4 IIIL..PPPP C-cor , (Continue on Back) -+ <br /> I <br />