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., 0 .-- 9-75-75n SG <br /> ZONING PERMIT APPLICATION www.countyofda e.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NAME <br /> Zoning Status; CUP; <br /> )kr <br /> NER ADDRESS (Numbs treet,City,State,Zip) Deed Restriction; CSM <br /> S OCL(� Y11✓i(� Or [5. 5� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .I V g 2 ,o • -Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> r <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE Plan approval from <br /> plicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT Z ING: ACREAGE: -vation of property <br /> PARCEL Dbg 091 D- 4104-61//1—.5 K - / @ �3/4 \ outage drawn to scale. <br /> NUMBER l= <br /> TOWNSHIP: SECTION: <br /> (A)i OM r 3 0 1/4: S ) 1/41%: _ rive •-rmits <br /> rr__ Nirtkor ' I G (st to -•■ ty,town) <br /> ADDRESS: <br /> (9 .2_0 S. D, k- �l kle i i 5 anita mits <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT publ' ,p 'vats) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> �/ g)C iO s 2C� oning District <br /> IJ This project is a new building or structure. <br /> Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: J Ira ` <br /> ❑SEWER SEPTIC / ne existin. <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Qfor 7 . S etian.P1 ,•.lain/ <br /> SQUARE FOOT <br /> (Outside ?±ctiment) <br /> AREA TO NEAREST S <br /> Q <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> Ero •nCon •)permit <br /> ,�, •TOTAL SQUARE FOOTAGE: ,t, slopes, ; rb <br /> 2ND FLOOR: 3RD FLOOR: `'' ~ <br /> S ' 'eview • u '= <br /> ESTIMATED CONSTRUCTION COST: ) T O O <br /> -� —► ..+ —► � --► =nd avail: •��-�+s*�onS. <br /> (Please round to nearest dollar) ;. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EJ No R Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes UfNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? UYeS ❑JVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ONo <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 ,lti,✓No ❑Don't know <br /> ❑ - <br /> 7. Is this to correct a violation? <br /> Yes '(No <br /> APPLICATION MU BE SIGNED <br /> 545-112(4/08) (Continue on Back)ST -i -♦ <br />