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• . GU5TOMtK TU PKUVIUt, <br /> OWNER NAME <br /> R t lJ-t t, J ev llc li4. �'c:- i .�r C-�v-:'(1:� ®Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City.State,Zip) Deed Restriction; CSM <br /> Ot(O I\It) iV, C UC',k >r�c,r l� I c-. 6-v./ Variance(# ) <br /> HOME PHONE I CELL PHONE I E-MAIL ADDRESS <br /> �3 a� -' —2t111 ` ck i,- n�.kor (.1''`\`-``�P''IN°fi ®Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME + CONTRACTOR NAME <br /> 420 t V\C\\cc.t:\ L ;,,��, TIN i, 'Rr1�,c emu 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic e:..5_ey <br /> S(D5 ki <br /> r �i. 13� I tik� � �� Ave_A,: t• <br /> (C+i,State Zip( U .(City.State,Zip) ®Setbacks <br /> PHONEv PHONE El Site Plan approval from <br /> L -- i-1 =31 f► I L,;S Z 1 2.. Ylf (.-7 applicable township. <br /> E-MAIL.ADDRESS E-MAIL ADDRESS <br /> 'v 6Ta, t-a e4.a A Ft.P'ti , t co,,,,, c c . IE Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdane.co.dane.wl.us/) CZ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: <br /> ['PARCEL 5y9_ ,23_d77 lc- _ a frontage drawn to scale. <br /> NUMBER c� <br /> TOWNSHIP: SECTION: <br /> 14 itt i�,�-Y--- 0 Q 1/a: 5 1/4%: 1 ®Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT I SUBDIVISION BLOCK/LOT ©Sanitary permits <br /> 0C.1I S00 <br /> 3 7 I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> -RwEC; ..ESCR:PTiCN <a <br /> `U Z tDistrict <br /> . ['This project is a new building or structure. <br /> ler►nitted ? <br /> oThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: I PERMIT NUMBER. RuratAddreSs : .' <br /> EWER [)EPTICrteWleXisttrtg <br /> HEIGHT IN FEET: :NUMBER OF STORIES: (Not including basement) <br /> 1 'U Weitand/Floodpiain/ . <br /> AREA TO NEAREST SQUARE FOOT: ,S i land t ttachment) <br /> (Outside dimensions including unfinished area. attached garages and above grade decks or porches) <br /> BASE ENT 1S ."LCCR iio- iori `63nt1'orp@RTlit <br /> ,l, TOTAL SQUARE FOOTAGE: ,.,(slopes,;disturbance, <br /> 2ND FLOOR 3RD FLOOR: fil�i�lgfaCSS} <br /> O.O Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) "i ♦ "� "� -I. -. I. 0 L <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes ao ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eves o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes JNo <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 -y! o Don't know <br /> 7. Is this to correct a violation? QYes F a <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -$ -► <br /> _.5-t12(Mg) <br />