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FNING P8 IT APPLICA11ON w ,racy 1ycidanacom <br /> i rRnr[RTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> _0_i i ta,941(,VA `" --- <br /> \ J' 4 ning Status;CUP; 4''/. <br /> as (Nun1Der'Bite*, , ) ��Q'3 Deed Restriction; CSM <br /> MHO Cot. rA J}- eA, ✓ ��uvr�b�� LA.).7:— Variance(# ) <br /> HiAIE E CELL PHONE E-MAIL ADDRESS <br /> • I •255 O$. 141.2_554 „ • �x • iti t3'1 • ,„• 1!-co t.f! Site Plan drawn to scale <br /> AGENT INFORMATION CONYRACTOR INFORMATION -nd includes dimensions Vu AGENT NAME CONTRACTOR NAME <br /> S.QJ r- <br /> .:4 Site Plan including location l <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic / <br /> (City,State,Zip) (City,State,Zip) Setbacks 757q 2/q/4/ <br /> PHONE PHONE Site Plan approval from <br /> applicable township. �A- <br /> E -MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale f <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) /�, n^ <br /> PARENT PARCEL NUMBER: U ENT ZONING: ACREAGE,; . AElevation of property �C <br /> ❑N MBER D / (/—/ ���� r A ,-/ /v�J, ( S frontage drawn to scale / <br /> TOWNSHIP: -1,I 1 S \ SECTION: '/• 1/ IV 1/`%; `/ 1 1 gDrivewa •-1 its <br /> ADL�REss: //w /�/ Y� /V YV /�^�(state, ou n own) <br /> ISanita •-II its <br /> CSM: LOT SUBDIVISION BLOCK/LOT ubIIC j] <br /> (P <br /> PROPOSED PROJECT INFORMATION '' REVIEW <br /> PROJECT DESCRIPTION: �'.' <br /> �►o� 1�itienan c-,��., s -e J /V x' 1S arZorti . ._._ . - 14 r-/ <br /> . ��i his project is a new building structur tl�.t err Use? �' <br /> II This project Is an addition/alteration to an existing building or structure. r't-+-� <br /> SANITARY SERVICE: PERMIT NUMBER: r�' ��% . _ <br /> FIEWER r)EPTIC (n ,{ �' i ;) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) * <br /> IW, - .. ... . ., n/ <br /> AREA TO NEAREST SQUARE FOOT: = (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionCOntrol permit a. <br /> BASEMENT: 1ST FLOOR: '/ <br /> 1�pC�7�• Al X "1 4 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, 10 ` <br /> tilling/ac cess) <br /> 2ND FLOOR: 3RD FLOOR: 4U /Q /� r <br /> ESTIMATED CONSTRUCTION COST: //J 1/° zi Review Location p Survey/'4L <br /> (Please round to nearest dollar) "r "♦ ♦ "♦ ♦ .� 5-0 0 and avai{at�e options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a. ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es DINo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es po <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 "lo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ca. <br /> APPLICATION MUST BE SIGNED <br /> /Pwniln..a nn Re•Lt J J J <br />