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SUPPLEMENT to Web-App # <br /> ZONNG PERIVIT APPUCAI1ON vwwkcountyo(dareoom <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE' <br /> OWNER •• <br /> 71 / ping Status; CUP: <br /> Nt OWNER A R ( �mber,Street,City,State,Zip) eed Restriction; CSM <br /> LLHONE ar/ance(# ) <br /> HO7NE PHON CELL•HONE E-MAIL ADDRESS <br /> 4. /t. ' j 1' S% e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION ii d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Sit Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS Of ell/septic <br /> (City.State,Zip) (City,State,Zip) Setbacks <br /> PHONE a PHONE ❑ Ite Plan royal from <br /> pplic e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) '_ Elevation of property <br /> PARENT PARCEL NUMBER: 9 1 /�(�CURRENTZONING: ACRE // <br /> ❑NUMBER ©(O© V�1 i"Ct' ' © Xf frontage drawn to s le. <br /> TOWNSHIP: SECTIQQvv�� _ 1 ^ /1 w'/I <br /> �: I V K v %I/4: Id f-_-_-, ❑Driveway mits <br /> S //t l �� (state, unt wn) <br /> ADDRESS C L <br /> ��2DIVISlON< `�J <br /> ❑Sariita permits <br /> CM /� OT BLOCK/LOT I.ub <br /> , private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION. 011tr ` oning District <br /> . project is a new building or structure. ❑ Permitte project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ddress <br /> EWER PEPTIC (new/e fisting) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not includi�g basement) <br /> ❑ Wetland/FI plain/ <br /> Shorel (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionContro ermit <br /> BASEMENT: 1ST FLOOR:c23 <br /> 1 TOTAL SQUARE FOOTAGE: ♦ (slopes, di rbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/a ess) <br /> C� 7 ❑ R iew Location Survet\ <br /> ESTIMATED CONSTRUCTION COST: and avail le options. I v �, <br /> (Please round to nearest dollar) d 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (lea blan if none) <br /> 6. Is a location survey required? (see reverse) es No ['Don't know <br /> 7. Is this to correct a violation? es ❑NO <br /> 3 APPLICATION MUST -- SIGNED <br /> I (Continue on Back) -♦ -► -, <br /> 545-112(4/08) <br /> t <br />