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- <br /> PROPERTY OWNER INFORMATION _ CUSTOMER TO PROVIDE <br /> o ER�N�AX. <br /> �tENI e' -e` C_ --• ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) _Q Deed Restriction;CSM <br /> 3 4/).0).o .aM Or, StoukL W ' - 7 g Variance(# ) <br /> HOME PHONE CELL PHONE _ E-MAIL ADDRESS <br /> CA- <br /> Z09-49c-5YC7 el k ereAoe `, 9'1 l -c.c4i ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME . <br /> 5ek.41 So`M ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE <br /> Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:Uaccessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUM ER: CURRENT ZONING:, ACREAGE: <br /> ❑PARCEL 06// /q3 gaOoS FP .3s' 1 jg q frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: S SECTION: <br /> P(�CA.S a,v C r <br /> V1 /'t 14:7,0(„ N '/:R I I E ElDriveway permits <br /> ADDRESS: t `) (state,county,town) <br /> a`f 3 i 14 U,/ a N ❑sanitary permits <br /> CSM: LOT JSUBDIISION L BLOCKILOT <br /> Po-ec.c` owl^ /13- (public,private) <br /> pli:lel;MA A1111:d:?•!R1 •.ATT. ii :171:ii - - .. " STAFF REVIEW <br /> PROJECT DESCRIPTION: ` i <br /> pc,t-e- S h iL ❑ Zoning District <br /> [A.This project is a new building or structure. <br /> j Permitted Use? i <br /> ['This project is an addition/alteration to an existing building or structure. l <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address aa3 <br /> (EWER 1)EPTIC (new/existing) <br /> HEIGHT IN FEET: I �,. NUMBER OF STORIES: (Not including basement) <br /> Z 0 Wet#and/Floodplain! I <br /> Shoreland (attachment) 8 <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) "4-1 <br /> BASEMENT: 1ST FLOOR: ErOSi4n�Ontr01errT It <br /> 1 {, TOTAL SQUARE FOOTAGE: j (slopes,Lisur Uat ice, i <br /> filling/access) i <br /> 2ND FLOOR: 3RD FLOOR: ^ O I <br /> Iill LI Review Location Survey I <br /> ESTIMATED CONSTRUCTIONCOST: ♦ ♦ -� d'$ �/S'OU �O and available options. <br /> Please round to nearest dollar) i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes jNo ❑Don't know <br /> ❑ <br /> 2. Is there a wetland or floodplain on or near the property? Yes EIN. ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Yes lNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ONo <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) ❑Yeslo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> REV(01/19) (Continue on Back) -► - -+ <br />