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ZONNG PERIVIT w ,CATION con SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE AME <br /> NoL( F( 5 L 1i 13 e r ['Zoning Status; CUP; <br /> OWNER ADDRES umber,Street,City,State,Zip)�� A // L / ' Deed Restriction; CSM <br /> 44) O(/ l✓1 e, 6k7 1 v C f /Vl r Pie V -.f�+'1 WI SS( Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> L • -6--• 5 El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 7;4/ L m 6 er�son 4v►'t w`I co, 44 qge /dl 'S • ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /2o4 'Ate 4.pµi5f he• S)c, 4hheN t% 1e <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> 7 <br /> PHONE V et/01,14 r /j 1• 5 3S-9 PHONE c P1 ?Yti eft /cd/ 5`.3si? 0 Site Plan approval from <br /> e / (0 f2 S' PE5.Co applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation of property <br /> E]PARENT PPAAR�CEELNN MBER: �j QCURRENTZONING: ACREAGE: p P y <br /> PARCEL NUMBER V�.�1N�0fJ'3/¢�J,�J6 R ti• ' ,?, frontage drawn to scale. <br /> TOWNSHIP: // SECTION: <br /> S 014 t- - i f '/4: yoh: ❑ Driveway permits <br /> ADDRESS: �_ /' ^A /_ {,, (state,county,town) <br /> 4 i o�O ?/ - Ci e C!-" e • 1 iie4 i 1 'i 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> /5"/Co. R (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> a1.F 1 x 241 1)e i.c% 44.--49e ❑ Zoning District <br /> . lEfThis 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 /> DEVVER DEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3 /► a /7 f C.(� eh t! Li Shoreland Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: ,` (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> `•? (O ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ �[ and available options. <br /> (Please round to nearest dollar) ' O- <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ENo Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Ey ( <br /> es No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Wes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑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) Eles ^No Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -+ <br /> 545-112(4/08) <br />