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SUPPLEMENT to Web-App# <br /> Cunha rcrtmi I HrruvH i min wwwcountyoraane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OVER NAME / / `` // <br /> / /G∎YiGIAr-t Anzg�(4. At.c ho(so L, ❑Zoning Status;CUP; <br /> OWNS�°DRESS (Humber.Street.City.State. ip) ^ <br /> bit L. 4 CD 6, 4✓C S -D✓ 1.., �� ALI. S33-25 Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE I CELL PHONE iE-MAILADfFR SS <br /> 16 fg—513-/I Y 1 { 1.?A . . se. ,7 7 b I24avt-,: ID - Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS I CONTRACTOR ADDRESS of well/septic <br /> (City.State.Zip) I(City,State,Zip) ❑Setbacks <br /> PHONE I PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS !E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (Ihttp://accessdane.co.dane.wi.usl) <br /> PARENT PARCEL NUMBER CU TENT ZONING ACREAGE ❑Elevation of property <br /> ❑NUMBER 0 / I ".33/-y l?( -q I /1-10..- 0 . 3"q I frontage drawn to scale. <br /> TOWNSHIP I SECTION / <br /> ❑ <br /> /'ale a S 4 n F S t•; S 1 3 '/4: S /l) '/41/4: A E Driveway permits <br /> ADDRESS (state,county,town) <br /> CSM LOT I SUBDIVI ION BLOCK/LOT ❑Sanitary permits <br /> 2 1 I , l.- r/drs (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIpON t// / <br /> /je.v' 2eS; Jed -. I 1-/O,t4 e- LI Zoning District <br /> . EjThis project is a new building or structure. LI Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE I PERMIT NUMBER LI Rural Address <br /> (EWER 3EPfIC i 1 — )01 7 -000 C7 5--- (new/existing) <br /> HEIGHT IN FEET 1 ii j NUMBER OF STORIES (Not including basement) <br /> I i LI Weti and/Flood plain/ <br /> 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 LI ErosionControl permit <br /> /98-C- .3 /ry ♦ TOTAL SQUARE FOOTAGE: ♦ (slopes,disturbance, <br /> 2ND FLOOR 3RD FLOOR: filling/access) <br /> l vD <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) 4)�'y c/ O 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des V4No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes DINo <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) [Yes INNo ['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(4109) <br />