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ZON1G PERMT APPLJCAI1ON wwwecouvofdare.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> � / <br /> da vA, P , ,Zoning Status; CUP; <br /> OWN <br /> l�lR ADDRESS (Numbs,Street,City,State,Zip) A <br /> Deed Restriction; CSM /0E.92- <br /> HOME ( L- I �CELL PHONE. *a�As o ADDRESS <br /> a t 5- 371( / Variance(# ) <br /> �i 1 2 4C.- S K-E e 4 4( Lr �O Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including locatio <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/sept' <br /> 30 <br /> (City,State,Zip) (City,State,Zip) Setback /OA/ <br /> PHONE PHONE Ili Site Plan approval from i <br /> applicable township. <br /> /V <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn '� Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P p y <br /> El 1/4J 01(o313%VWo gtt-i '2-6'2- frontage drawn to scale <br /> TOWNSHIP: SECTION: <br /> Tt OOM.i N r ROUE 3 2 1/4: �/1/S� Driveway permi <br /> ADDRESS: <br /> 7 (state,county, own <br /> 1'(1?j (- Lag /tit 14- 1501\J lit) ( Crif1 laSanita �•- •'.its <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> I3bI . <br /> (publi•�•�11t <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: pp <br /> So L,� TAN - ,( P-R / 32- /x f 2- X 1, Zoning District kf -/ <br /> . I(his project is , new buildin• Ir structure. lPermitted Use? sre,/4 <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: OEPTIC PERMIT NUMBER: 04 Rural Address S >�EWER (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I g'f ( i■' -'• A oodplain/ <br /> horeland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) 04..., IQ(CAMrOI permit <br /> BASEMENT: 1ST FLOOR: ' <br /> 3g44 2 + TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, igi 1. <br /> o fiiling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3t l X!:eview Location Survey //////. <br /> ESTIMATED CONSTRUCTION COST: 000 <br /> nd available options. /�/�� <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ( 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes [NiVo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? OYes ao ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? IJYes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes Jlo <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 ao QDon't know <br /> 7. Is this to correct a violation? ----- ['Yes to <br /> 5 () APPLICATION MUST BE SIGNED <br /> �./� ��t - (Continue on Back) ■ - --► <br /> 545-112(4/08) <br />