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[ PQtH!CESN,JBQC ADBUJ-Oxxx/c votzp /c n SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Dttigk, ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 4/4 1 Ot Stu �j/bdk� `n LA)( 535z-( Variance(# ) <br /> HOME PHONE CELL PHONL 1 E-MAIL ADDRESS <br /> 45.5—3a 25 el,eo ll(77G' a.cvm ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> l t-4✓b- o-YL ❑ Site Plan including location <br /> AGENT A RESS CONTRACTOR ADDRESS of well/septic <br /> it(, 22 Ao <br /> (City, te,Zip) (City,State,Zip) ❑ Setbacks <br /> tr14-Ct r. <br /> LA 535 z( <br /> PHONE PHONE ❑ Site Plan approval from <br /> 33171-&( l applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> OA eaeoik A14-00,c0)1't- ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: LI Elevation of property <br /> ❑ PARCEL ZC2-) 3 Z frontage drawn to scale. <br /> NUMBER 55z-O50- 1 q((-1,05-0 bit t <br /> TOWNSHIP: .-��rr,,' Q SECTIMI: <br /> R C ❑ Driveway permits <br /> U.` 1( k ` 1 1/4: N C 1/41/4: J <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> t ICI,2 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> 11'This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: t t� r PERMIT NUMBER: ❑ Rural Address <br /> N NE <br /> ❑!SEWER ❑!SEPTIC 0 z l 2 0 o_5 © L Q 3/ (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3 2 - ( ❑ WellaWlooc>OlaiN <br /> AREA TO NEAREST SQUARE FOOT: Shotad (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: !(�J4x/ <br /> 15 ]J TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ) 5 filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -�► -► 0 and available options. <br /> (Please round to nearest dollar) �0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Ltno ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes L 'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Gd5'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? C17Yes ❑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) C<Yes Li No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes LiNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ --0 —► <br /> 545-112(4/08) <br />