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ZONING PERMIT APPLICATION www.countyotdane.com SUPPLEMENT to web App;# <br /> PROPERTY,bOWNER-INFORMATION; ,, .,gx C STOMER TO O PROVIDE <br /> OWNER AME l' ect.,\A(ke \i-^ <br /> YY 0.. /A Q-- (`j R)•..4 v- l C l GLr ` it Zoning Status; CUP; <br /> OWNERADDRE{S (Number,Street,C' State,Zip /' ) D ed Restriction;CSM <br /> .c-/y,� Oct /L ]'Q..r `� Rcl /' 1 Q. r SA a-// bui ariance(# ) <br /> HOME PHONE CELL HONE E-MAIL ADDRESS 6 J'✓ S-9 <br /> .A i p S-- 0 Y ite Plan drawn to scale <br /> 'AGENT INFO_ RMATION, `' ,_ :CONTRACTOR INFORMATION, `° and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> • e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ' ❑ ite Plan ap val from <br /> applica ownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS • <br /> Floor plans to scale <br /> � , <br /> '.-PROPERTY/LOCATION INFORMATION '(http//accessdane co d_ane wi;us����,�� Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ONING: ACREAGE: P P rty <br /> ❑PARCEL ©g l 91 . 4©a i..(� (�^ � 1- 4,02 frontage drawn to scale. <br /> NUMBER jZ <br /> TOWNSHIP: SEC c T Y: P C.:: % : J W l <br /> ❑Drivewa ermits <br /> i � / f7 <br /> (state ounty,town) <br /> ADDRESS: / / p 1- R C�- I/ /(k -Sh ?' <br /> �-i( 5-�-�5 ❑Sanita ermits <br /> CSM: LOT SUB I SION BLOCK/LOT <br /> (publi ,private) <br /> • . - L • ; I I : • - ;STAFF REVIEW <br /> PROJECT DESCRIPTION: / =rte <br /> .o X 30 tiCt'ee S�� I Q to(� fl rornngDlstnct ` z <br /> ❑This project is a new building or structure. V. Permitted UseZ <br /> ❑This project is an addition Iteration to an existing building or st ct re. t "_ q= "� <br /> SANITARY SERVICE: PERMIT NUMBER: A 1 ® Rural SS i <br /> EWER EPTIC /v _ (new_ exlStln <br /> HEIGHT IN FEET I� NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/FI plain/ <br /> 4 Shorela `(atttach% tit) <br /> AREA TO NEAREST SQUARE FOOT " <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) > r - <br /> BASEMENT 1ST FLOOR ❑ EroslonCo OI p'ermit <br /> Q 00 j, TOTAL SQUARE FOOTAGE: 4, fl iSlopes •.. turbance <br /> VV 1 f lltrig"7 cess f c <br /> 2ND FLOOR: 3RD FLOOR J c Q a 1=-- . { A <br /> ' t.. <br /> r� <br /> fl Devi Lcatlop Survey <br /> ' } " On <br /> ESTIMATED CONSTRUCTION COST: -an d avallaife o ptlons <br /> r <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ? Q Q O ' <„ _ w , t `; <br /> J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es Ui • <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - [ Yes gri • <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank• one) <br /> 6. Is a location survey required? (see reverse) ❑Yes ,N,t o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IN <br /> o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) .9 -I► -* <br /> 546-112(4/D8) <br />