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�NG �APPLJGATION wumnitoour>�yofclar oom SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION ( CUSTOMER TO PROVIDE <br /> OWNER �� A \/"'/p11 �"c( r �"I <br /> J/J� LI Zoning Status;CUP; <br /> OWNER ADD ESS (Number,Street,City, te,Zip) Deed Restriction;CSM <br /> /�/� Cs r -)--(t(1 Cs)]Ur,16� US C'- 5-59;6— Variance(# ) <br /> HOME PHONE 'CELL PHONE E-MAIL ADDRESS (� <br /> G9-7/ 1-(,_),`,10 1-(,_),`,10 rar t1 kt,,Can-, LI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> LI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of wellseptic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE LI Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> LI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdane.co.dane.wl.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE. <br /> ❑ EleVatlOn Of property <br /> ❑ PARCEL Glia/OCTi_141 )1300 A - I , g 3 frontage drawn to scale. <br /> NUMBER lam/ <br /> TOWNSHIP: (( SECTION: <br /> 6 r1STC)l '/a: '/<'/<: LI Driveway permits <br /> ADDRESS: (state,county,town) <br /> I( S Estes fctt <br /> LI Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> / O D€U I t C,��k (0 C (public,private) <br /> PROPOSED PROJECT INFORMATION U STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ax &YJ(V, P0O/ `t OeC� ❑ Zoning District <br /> . <br /> This project is a new building or structure. <br /> `❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: LI Rural Address <br /> ❑SEWER kX SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Stl;,,, LI Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ jQ/ .-- and available options. <br /> (Please round to nearest dollar) l 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? t Yes LI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 'Yes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? LI Yes A 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) LI Yes ' No LI Don't know <br /> 7. Is this to correct a violation? >S:tYes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br /> VrN.k.,0 11-/t tr^e d& <br />