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ZONNG PEFIVIT P CATION Kco can SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME r <br /> R4M 01,1(Number,O kt!JS�, : ing Status;CUP; <br /> OWNS ADDRESS Street,City,State,Zip) f' Deed Restriction;CSM <br /> /011S- 6Av-root Rd. Cvc&s Pko,& GI); 5352 12, Variance # ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRES <br /> '0 i L ' Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ''//--4�I,, cJ10/ Ytllld r3.. n including location <br /> AGENT �� CONTRACTOR ADDRES ofwel/septic <br /> /A04 &#,fee ;6e i),, S2L <<i,hteaei b/i. <br /> (City State,Zip) (CiStates,y, Zip) etbacks <br /> PHONE ' ' ` " S 93 ,Ir ;rle1 ��. 3�1 ❑Site PI pproval from <br /> 22 s, /S Co 2 5 -P 6.G0 5 appli I township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r. "Y c ® j e, - p.F,enriclans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevate property <br /> y <br /> 0 PARCEL ^ 0 1 1-73 7,S a j'>A _Z S, -Z, ) fr ge drawn to scale. <br /> NUMBER l ' !� <br /> TOWNS IP: SECTION: <br /> LevSs pI/14 3 '/4: '/4'/4: In Drive y permits <br /> ADDRESS: Rd (st e,c nty,town) <br /> 4°/5` C4,-'��� R / Sanit ermits 1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 30 3(O i (public 'vate) o <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: - / <br /> 3 a' X 30' Z e /GAG ti eU 6- 4,45.-e u- . <br /> District <br /> his project is a new building or structure. <br /> ermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: l •• ess <br /> DEVVER , EPTIC (n <br /> HEIGHT IN FEE I NUMBER OF STORIES: (Not including basement) <br /> Q -..4 loodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Sho Ian• ;- rchment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) a rosionContr0l permit <br /> BASEMENT: 1ST FLOOR: <br /> U x„10 /—5- /w_/ 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> fillin access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1(7 s (o eview Lo tion Survey <br /> ESTIMATED CONSTRUCTION COST: //'' and available 'Ons. <br /> (Please round to nearest dollar) ♦ ♦ '"� "-� -'i '-'0. $6;16 0�, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Byes ❑No Don't know <br /> 2. Is there a wetland or floodplain on or near the property? EJYes No Don't know <br /> ^ <br /> 3. Have you talked with the township about your project and are they in agreement? Elies No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? UYes ❑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 RNo ❑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(4/09) <br />