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SUPPLEMENT to Web-App # <br /> LVlvinu rtr ivii I Arruvitlivni www.countyomane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Li z-4 Uca Air- cpcii ❑Zoning Status;CUP; <br /> OVMIERADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 170 55 c 10:10e-LKDtAi ( 1)/ NIC FAltLArcD / PV 53 Vq3 Variance(# ) <br /> HOME PHONE (Doe CELL PHONE (OQj E-MAILADMESS <br /> 141 .35-s AO 331a Li ZAot b.∎/aHt"araleint ' 'covr) [Kite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1,0 r4( ON LAVA 1: 0.-. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> 04,1A tXele /WS <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co_dane_wi.us/) ❑Elevation of property <br /> 7 <br /> PARENT PARCEL%M I T I z,3 ' CURRENT ZONING: ACREAGE <br /> ❑PARCEL 0-7/1" C, frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> IA: WA: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary perm its <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION- <br /> N &2 i 1 C1+ 1'. DU r/t/ ti a Ac1AGS, LI Zoning District <br /> . [ his project is a new building or structure. I_.I Permitted Use? <br /> ❑This project is an addition/alteration to an existing buildrg or structure. <br /> SANITARY SERVICE: PERMIT NUMBER U RuralAddress <br /> HEWER r)EP-nc N /A • (newleXtstng) <br /> HEIGHT IN FEET: NUMBER OF STORIES (Not including basement) <br /> I U Wet and/Floodptaitl/ <br /> AREA TO NEAREST SQUARE FOOT. Shcielan�k(attachment} <br /> (Outside dimensions Including unfinished area,attached garages and above grade decks or porches) <br /> N/4 1ST FLOOR ft <br /> BASEMENT U ErosionCcrtrolpe<In <br /> 1 TDUL SQUARE FOOTA GE: I (SIOpeSs dIS(urbant e. <br /> filing/access) <br /> 2ND FLOOR- 3RD FLOOR <br /> U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST and avalatile Options. <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 "' Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑yam o �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? I[ o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? L.ld'es [lo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 11 D •kb ) (leave blank i none) <br /> 6. Is a location survey required? (see reverse) Dies o �k; Joni know <br /> 7. Is this to correct a violation? ❑Yes [L$ <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) a = 2 <br /> 545-112(4/08) <br />