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ZONNG PERIVIT APPIJCiT1ON wwwcouitycidane.com Fl•1 J J�a r i i a• (•�.[7•D_1a.�:! <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> .t3g/u -Am IM Wing Status; CUP; <br /> OWNNERADDRESS (Number,Street,City,State,Zip Deed Restriction; CSM <br /> LROS" S C t�f N b t �2 TAW l� U� tit) /V/�/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL AD RESS / /I <br /> Cog-a(5-'7 _ 3 elts4-eu _soIvt'ft`aAS _/yretil r Si n drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ©,Sit'6lan including location <br /> AGENT ADDRESS CONTRACTOR ADDRE S of well/septic <br /> (City,State,Zip) (City,State,Zip) tbacks <br /> jNE PHONE 0 Site n approval from <br /> ap Ica a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS a n,' <br /> or plans to scale Ilea <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ron of property <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: P P rty <br /> UMBER Oa9 Ob1 v- 03. 00:5 AA-/- 6,410 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -rowN vF y.: yoh: ID Drive ermits <br /> ADDRESS: ���� (stat , ty,town) <br /> 1-M3 Sc(4NF 02 Di( OR 7oN ha_ 53575 ❑sari rmits /U <br /> CSM: La SUBDIVISION BLOCK/LOT " <br /> (pub , rivate) <br /> PROPOSED PRCJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> rid-CI-id o...r•• R Q L l ( Jeri- <br /> r w-i x b, Wing District <br /> . 4 his project is a new building or structure. <br /> 64 <br /> • his project is an addition/alteration to an existing building or structure. <br /> `ed Use? <br /> SANITARY SERVICE: PERMIT NUMBER: ❑' Rural Address <br /> EER ( EPTIC ( T' <br /> W <br /> HEIGHT IN FEET: , Y NUMBER OF STORI : (Not including basement) <br /> ' ❑ Wier_ q '..:,e _in/ <br /> Sh•re = (attachment) <br /> AREA TO NEAREST SQUARE FOOT: . <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1 ST F OR: ❑ Eros's Co,trol permit <br /> j TOTAL SQUARE FOOTAGE: 4, (slope •isturbance, <br /> 2ND FLO 3RD FLOOR: / 00 full••r -f. SS) <br /> Z- ❑ Rev', L.,'IOW Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ / 1 �D v and av-, - •le options. <br /> (Please round to nearest dollar) $ ! 5 Wo <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Res )o DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? es to f'on't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ekes IL'-�L`', f <br /> o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes lao <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 ril o EDon't know <br /> 7. Is this to correct a violation? Des ! o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -i -► <br /> Sa5-119 ra/ng■ <br />