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ZONING P T.APPUCA11CN wwof'J1 iacom SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM / <br /> ✓r5 11.C✓ Ei')c 1 I- <br /> 50 El Zoning Status; CUP; <br /> OWNER ADDRESS (Num r,Street,City State,Zip)�I I 1 c' 535-& Deed Restriction;CSM <br /> A,")70 S prry,. 17, / X) 5-6, 9 variance(# ) <br /> HOME PHONE CELL PHON E-MAIL ADDRESS <br /> Ca -5/4-79q) lire r 7 c keho-i-rne Cory" ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER o4 , 06 II—171 —76`12-9 R. - I . -7 c frontage drawn to scale. <br /> TOWNSHI SECTION: Rl\ <br /> P�teSav 4- Si)r.•-,.9 5 NiE '/.: N E '/h:5E7,T6�1j ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 477 o S p r.) I-4 I b v 5.4,- L.I-t,i , wL 53Sb 7 Sanitary permits <br /> ❑ ry Pe <br /> CSM: LOT SUBDIVISI (public,private) <br /> a Fti4-A ,1 BLOCK/LOT <br /> 5 4. spr kill <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> s 1-K 1,1 /NFC k bcc(c ❑ Zoning District <br /> . EIThis project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> R gEPTIC "` (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> !� ❑ Wetland/Floodplain! <br /> V Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErOSiOnCOtttrd permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: I� <br /> filling/access) <br /> l K/ d ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) 1X0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EjYes I io ❑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? ❑YesVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes alo <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) Ekes ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ENO <br /> No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -♦ <br /> 545-112(4A8) <br />