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SUPPLEMENT to Web-App # <br /> • Z.ONI NG PEWIT APPLICATION www.00untyafdane.00m <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> �WNER N M <br /> � ❑ Zoning Status; CUP; <br /> M State,Zi r _ Q t � I , \ �\+�c�T Deed Restriction; CSM <br /> �( 1 W l p�� (� Variance(# ) <br /> O ON CELL PHONE -MAIL ADDRESS I <br /> i�' g'34$1 I i/t.! i 8 )..6 Y1 .Y� i ❑ Site Plan drawn to scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includes dimensions <br /> �ENT N E M S1ONTRAC1TOR NNAMMEE,� ,�,/� <br /> C�`� ! f, l ).,y 4-V e se 1 ❑ Site Plan including location <br /> MT),41:.)‘ ES, �( O [ of well/septic <br /> �� � ❑ Setbacks <br /> dy,State, ) gur\. ,state,t� I � "`�'� ,HONE T {�( 1��IvV�S �� U Site Plan approval from <br /> P, qq ^¢s' .� �_ 5' _ I ' 'g applicable township. <br /> E-M.IL ADDRESS � l A ADDRESS <br /> I. '. • I∎te ,Zn sill; � ,`, ,p'- 4- ., Icr, ne ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> X PARENT PAR L NUMBER: CURRENT ZONI G: A E,. <br /> frontage Elevation <br /> drawn to scale. <br /> PARCEL © 10_ —S el V vim/. <br /> NUMBER <br /> TO■ SHIP: S TI ❑ Driveway permits <br /> Al,. ��VV�i T t in, �4%' 5` ' (state, county,town) <br /> .fte r I 14 a I j • ❑ Sanitary permits <br /> LOT ' SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJ��/�/\/`J CRIPT C.r �/V JCkO , <br /> ❑ Zoning District <br /> . , This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGhil IN FEET: NUMBS OF STORIES: (Not including basement) ❑ wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions incl tkl*i�ng un ished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASFMENNT: 1S�u�I G ST FLOO 2 i a(17-- E 4/` (� 14 X v, j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> I J I U filling/access) <br /> 2ND F (7 3RD FLOOR: 413tr‘i:5143 I <br /> O °I ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -i ♦ a�J DOO and available options. <br /> (Please round to nearest dollar) Q� <br /> $ 3$4-t,c <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? V(Yes ❑ o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 1 No <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) CI Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► • -i <br /> 545-112(4108) <br />