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SUPPLEMENT to Web-App# <br /> ZONING PEFIVIT APPLICATION www.00�rrty�ofdanhoom <br /> PROPERTY OWNER INFORMATION CU•TOMER TO PROVIDE•OWNER NAME l� ��1 �2 <br /> owNekADD/ (Number,stntrcny State,jip)fSOk) 4oning Status; CUP; <br /> J�s-Z 9 ` 4n e'/, pd/. 44/4.3 14/1, �/ ; 53 s_,9 eed Restriction;CSM ) <br /> ariance # <br /> HOME PHONE .�,t� C L PHONE E-MAIL ADDRESS <br /> i t r 3 W ® ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /3-tri bet soH eneair4„ 64 ,6/,‘.s. e Plan including location <br /> AGENT ADDR ,QNTRACTOR RESS <br /> well/septic <br /> /.Z 0 expel Se I✓t. c---2 1a Li�hoc;el b✓` <br /> (Ci ,State,Zip) (City,State,Zip) etbacks <br /> PHONE V ‘,S 0/10, 0/,� s 9 3 &41 Pdt( rj P t V , ,c 3 S 6 u;0 S. a PI approval from <br /> 2 S-. i (b(0122 v 2 3 6' / j a p' ble township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> G - 4' 7 N ' 6 ,1144, ( , I or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of <br /> PARENT /PARRRCELNUMBER:: CURRENT ZONING: ACREAGE: property <br /> El NUMBER Op. O2[ %b R a 5, s 7 rontage dra o scale. <br /> TOWNS IP: SECTI • �\ , I <br /> �l'e�6/ t? 'n: y 1/<: i}v J ❑Driv ay permits <br /> ADDRESS: v�3 te,coup , own) <br /> CSM: 9 0O` et [d- SUBDIVISION -tI BLOCK/LOT s�\? ❑S74rmits OS/sZ / ( ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT)DESCRIPTION:DESCRIPTION: <br /> .2.1 )( .A2 ' 1 e Li e f 4 p11/r r�se r ,oning District <br /> . IXThis project is a new building or structure. ✓ • Permitted se <br /> This project is an addition/alteration to an existing building or stru ure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural dress <br /> DEVVER PTIC (new/ xisting) <br /> HEIGHT IN F T: r NUMBER OF STORIES: (Jtding basement) <br /> t a. _ ❑ Wetland/Ft plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorelan (atta• ent) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionC permit <br /> BASEMENT: 1ST FLOORi L 234 4, TOTAL SQUARE FOOTAGE: 4, (slopes •isturbance, (■ <br /> filling/ •«-ss) <br /> 2ND FLOOR: 3RD FLOOR: Ell-■ <br /> Lv1�l1 <br /> ❑ Revie Location Survey i <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ r and avai ble options. <br /> (Please round to nearest dollar) $/....s- 0...f "�'� , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres o Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan ' none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑1'es No <br /> ----# (Continue Back) BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />