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ZO IN PERMIT APPLICATION www.countyofdan•'.s m SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> SCett- G€(1" <br /> ❑Zoning tat ; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed R S ctlon; CSM <br /> 9,66 `7 1zcrel trir1 a -s' yy4-iti t,.L S3s"-ef Variance ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ‘o. c73-07r 60s, 7/f 9;04 v eE llr 0-4) C4,441-4.-_, .,/,C7 ❑ Site Plan n to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan i c Ing location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well)/se c <br /> (City,State,Zip) Ci ,State,Zip 'ks <br /> ( tY ) ❑Setb <br /> PHONE PHONE ❑Site Plan prom <br /> applicabl to n p. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [' Floor plascale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation of prop y <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 0511 17/ 7 $17 frontage dr o scale. <br /> TOWNSHIP: SECTION: <br /> O1/11 kir k 1/4_ 1/41/4. ❑ Drivew }r s <br /> ADDRESS: (State' V" ) <br /> x-66) `fia-reV-ivi C 4 ❑Sa it .er <br /> CSM: LOT SUBDIVISION BLOCK/LOT (p �l,r.V t N <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: [ / <br /> Sited /1 X.10 r� Li zoning Dilnttrict <br /> . Mr his project is a new building or structure. Cl Permttte lse? <br /> •This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Ad• = <br /> EWER PEPTIC (new/ex ;) <br /> HEIGHT IN FEET: �� ff NUMBER OF STORIES: (Not including basement) <br /> �© 6 ❑ tland 1••, ,.'-/ <br /> IP <br /> AREA TO NEAREST SQUARE FOOT: Shorela '1.. - * merit) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR:I <br /> d ❑ Erosio•C• 'A •-T'mit <br /> 7 C1 + TOTAL SQUARE FOOTAGE: 4, (slop- , • - •:nce, <br /> f ilin• «-ss) <br /> 2ND FLOOR: 3RD FLOOR: <br /> if <br /> ❑ Review ••ty- Survey <br /> ESTIMATED CONSTRUCTION COST: and av: >- ► o,tons. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ 3_>.re <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes kil o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Pa• o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dies : No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes allo <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 �', • ['Don't know <br /> 7. Is this to correct a violation? ❑Yes FA o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />