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N � w w m SUPPLEMENT to Web App # <br /> PROPERTY OWNER INFORMATION •""�"`7" CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ri e<r k fre 5 Jp r' ci l [I Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi Deed Restriction;CSM <br /> 9-0 i til eiN L Lv, Variance(# ) <br /> HOME PHONE CELL PHONE Q E-MAIL ADDRESS /� <br /> "r2( - 21 69 2W -2._t d r PA•rP 5 S 't . c-mo,.. ,C 6.4.„ n Site Plan drawn to scale <br /> AGENT INFORMATION i CONTRAC TOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,ZIp) ❑Setbacks <br /> PHONE PHONE — ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (hltp //accessdane co.dane wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 0 Elevation of property <br /> 0 PARCEL 06'11—-L CI Z—MO_�J �,i 1 .1 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP SECTION: as IVC ,e 4he A),,,) <br /> teas + r,n 5 s D. 0 0: n Driveway permits <br /> ADDRESS: (state,county,town) <br /> N C�,, •C �ol n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> . r 11 ifi �vi4 G! 6,,,,,,,i0 0 v'f' ❑Zoning District <br /> . ❑This project is a new building or structure. <br /> U Permitted Use? <br /> El This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER ❑ Rural Address <br /> EWER %EPTIC (new/existing) <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not including basement) <br /> a / ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: 44112112. <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> 5 O f2- TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> filling/access)FLOOR: 3RD FLOOR: <br /> T lling/access) <br /> So ft' _ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) $ 101 Q 0 C) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 1, QYes ®No QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes IRNo LlDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? es nNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es to <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) rfres 10 QDon't know <br /> 7. Is this to correct a violation? Efres I No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) _ _ _ <br />