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6we'e,r ,--- cc_ <br /> �,,,r <br /> 1 r4utle F <br /> � <br /> �1G �/ CA1CN vwNkOOI�yofdanaO01Y1 �JPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME _ 1^ <br /> v 1C' CO r 'J <br /> i S ❑ Zoning Sta us; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restr n;CSM <br /> "7�-i - VaIIP nGA� JPTaNe<1 ll� Variance(# ) <br /> HOME PHONE dELL PHONE E-MAIL ADDRESS <br /> b08 Sys"(cfd17 8"QIJ)a`9/0 c le_ Ova - ahl )5L; f'c1(k ❑ Site Pla yawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and in des dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C Iea-tL 1U, idr,� ❑ Site Plan in ding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setb s <br /> V eitr14- UP I <br /> PHONE PHONE ❑ Site P n •,• :I from <br /> app' tst .hip. <br /> • <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plan t scale <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of pr erty <br /> ❑ PAR r frontage dr to scale. <br /> NUMCEL BER ��z/ol��U � 1�6a's /9-1 Csx) `�3 <br /> TOWNSHIP SECTION: <br /> VPCOI'M r)0--6—B" %: <br /> WA: ❑ Drive it <br /> ADDRESS: (state n ,t wn) <br /> ?tt5 4l- Vot I(F,. Poo (-C 11 to NA f c.) 1 6 3 / <br /> CSM: OT SUBDIVISION BLOCK/LOT ❑ Sa t �ef ItS' <br /> (p tiv.42: <br /> PROPOSED PROJECT INFORMATION STAFF SW <br /> PROJECT DESCRIPTION: <br /> M/tc ii A e s►ko A 1 f b�, /a1' 1Vor e d.�f l/ ❑ zoning STAFF <br /> . arThis project is a new building or structure. <br /> ❑ Perrttikh Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural A''ress <br /> pvO41k ❑SEWER ❑SEPTIC (new*l ''-) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> D e ti If +c pt a rt-e. ❑ Wetta .'° ;';sin/ <br /> s,o .,,, <br /> ent) <br /> AREA TO NEAREST SQUARE FOOT <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: r-, Eros''1 +• 'i. . - <br /> y� o 1t-e ;i1- ic 115-- ,, TOTAL SQUARE FOOTAGE: ,, (sbO'= . , •,nce, <br /> / 1 /t % <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 12 6, ❑ Review ® =' -y <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and . _ ., ,• S. <br /> (Please round to nearest dollar) l 500 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes "lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ..Yes ❑No ❑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 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) ❑Yes tlif No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes xiNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/081 (Continue on Back) -♦ —► -+ <br />