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ZOII NG APPUC1T1 VN wwwwourtycidane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE NAME 1 I .�I <br /> r(L�Q m d- � , W 4i ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State„Zip� ,.n Deed Restriction;CSM <br /> 3 IV 0 l0 Ni e r Fief' bi l t-c.- rh at W 1 5351 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 1_ <br /> (rDg;48"08O 6 Ame- eme mk-�-c- , HILT <br /> OS 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> N a c.h,cti e) v Cbn-S+Yttken ZIC 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1 0-i 5 1 2 r aGot d RA, <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> PHONE PHONE h W �3 yg <br /> ❑Site Plan approval from <br /> t p$ - sL `i _0753 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (hltp://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL O I D-li b Olp.-b -97x-I g 14- ( $.9 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> g lh bu n d S � /: / /: 0 Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> Sao to Mr AN- Pd , ' '1' 4.. (11 A 4 . WI 53S / 9 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> A 5 S k�.d 8[6\5 ❑ Zoning District <br /> . EiThis project is a new building or structure. ❑ Permitted Use? <br /> DThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> DEWER EJEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I I I ❑ Wetiand/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: r—, ErosionControl permit <br /> I _3 bn 44 Jr TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: : filling/access) <br /> ---. P°r ck a tf` ir5SO ol, okOta ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ and available options. <br /> (Please round to nearest dollar) $1 Oflip b4 <br /> r7o, cjOO. co <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EJYes slo aon't know <br /> 2. Is there a wetland or floodplain on or near the property? fYes o DJon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ►o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes llo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# Z--7g67 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) EYes o Jon't know <br /> 7. Is this to correct a violation? Eyes �Vo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4108) <br />