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. '' ...- 3 `.--)) Li�'� �0 <br /> ZOM■NG CATION wwato3untycidere.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME :rim r, i wT" n - p <br /> Illp <br /> i L 3 v N I . .,,ti s.�.- VV] CSI c'- C % o).- <br /> OWNERADDRESS (Number,Street,City,State,Zip)? - Zoning Stat s; P; <br /> Deed Restri 'on;CSM <br /> 9 S 11 O 40 1 I Piet'. 6" 't I- y Of-S'�s;/7 Variance(# ) <br /> HOME PHONE CELL PHONE / E-MAIL ADDRE$S t , <br /> '7C a5.2-//, 77/x-3 ).- 14 '7 rob Fir t__.,14r„e( L lrac, Ci, n <br /> 11 Site Plan dr wn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and inclu4es dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /4r'k tie.ef 2 A ,rill/and -6(44,t4 '1.5 0 Site Pia Including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of we eptic <br /> 3er0 /714.4v, 51. 3 Kv mall. SI- <br /> (City,State.Zip) (City.State,Zip) 0 Setba( <br /> Bra+v-►�s,,*li, 1.)S' c 3oDi 6rooy►sv.Ile). &I' Sic 1.‘ <br /> PHONE PHONE Q Site Pla from <br /> 4 ad-- 5*3 -a Ssy 4 a�L%'--.mod'3— a 5.sy applica e iiil <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r(►erf cttlnart'i•14rnd414.:id, , c'Wl kerl-zaL g nvr-ti 14,441411 Cc4) El Floor plans tole <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: <br /> Elevation o PARCEL i 071/- 113-8S7D--8 A'H-y 1)&67 6� j, /5S frontage dr scale. <br /> le.P ER <br /> TOWNSHIP: SECTION: <br /> Tcits.•.. cI- (af/ JQ tc,-rov._ .1/4: IRA: ❑Driveway p i <br /> ADDRESS: (state,coun <br /> av r r uoL�F1 ,2d, (c arts. ere' we �., s—XS—a2 1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sa ,e0 <br /> / <br /> (p • 17'v ',f <br /> PROPOSED PROJECT INFORMATION STAFF Rya IEW 7 <br /> PROJECT DESCRIPTIO : (3i, to u� <br /> Siera/f i�ad-r- t. ,4 14'itet .- i` /2 'Ai 'L D-n Sia, I ❑ Zoning ct <br /> IThis project is a new building or structure. ! ❑ Permittet>I le? <br /> This project is an addition/alteration to an existing building or structure. v <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> 'EIMER j EPTIC (new/e l p) <br /> HEIGHT IN FEE : �r 1 NUMBER OF STORIES: (Not lnduding basement) <br /> M lt' 1 l ❑ wetla • i •• �!'1 / <br /> ARShorelan TO N . melt) <br /> NEAREST SQUARE FOOT: 1 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ Erosion o :rmit <br /> BASEMENT: 1ST FLOOR: <br /> /7�t r' +,TOTAL SQUARE FOOTAGE: + (slopes 111,l -4 ance, <br /> O filling/a •---) <br /> 2ND FLOOR: 3RD FLOOR: / <br /> f_ oat ❑ Review o�<sl•n Survey <br /> ESTIMATED CONSTRUCTION COST: and av- el-n•tions. <br /> (Please round to nearest dollar) "♦ ♦ ♦ '♦ 'io '♦ $ 5 j 7 t�-0v . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes IVo QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes o JJon't know <br /> 3. Have you talked with the township about your project and are they in agreement?.- Ekes LVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ®1'es EINo <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) QYes * o QDon't know <br /> 7. Is this to correct a violation? QYes e i o <br /> APPLICATION MUST BE SIGNED <br /> 545.112( ) (Continue on Back) -0, -► -4. <br />