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)Nw PERIYa 1 APPLICA MN wwwv.countyotiane.corn SUPPLEMENT to Web-App# <br /> I <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1-4\R42-k(. J ,c,.'o t3b0� ------._...... ❑Zoning Status;CUP; <br /> OWNER ADDRESS(Number,Street,City,State.Zip) Deed Restriction;CSM <br /> ??- ..__CGu ri C'.t� vi. GI4."4:1 .D( ..._S35-zs Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> CaOG•51-7-314 fl Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> +'pw `\`e� (fir rt...c„k-n 1..u... []Site Plan including location <br /> AGENT:ADDRESS CONTRACTOR ADDRESS of well/septic <br /> it kA.• 1,,J. M lit is S1 <br /> — —__........__ ❑Setbacks <br /> (C ay State.Z p7 ,(City State.Zip) <br /> j✓. "(N)s.. `- S3 6 <br /> PHONE PHONE ❑Site Plan approval from <br /> _Qc,3--75 I -Lmas applicable township. <br /> E-MAIL ADDRESS ;E-MAIL ADDRESS t <br /> 1 #� `,a c01 y •k ,((y,, ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httprl/accessdane.co.dane.WLusl) Elevation of property <br /> PARENT PARCEL NUMBER`G l� p��y(y,.CCURREN ZONING: ACREAGE. frontage drawn to scale. <br /> TOWNSHIP.NSHIP. _..... ,O��c��''.T I. �1 j0i-�_�!`..a S' C �t s£ 1 <br /> SE..TION: � �Driveway permits <br /> NQtST 1 N f4 1 '14-102 /,: lf� 'h'/,:... state,county, <br /> _.... .. f4_.._—. — ---.. _......... ( rer town) <br /> ADDRESS Q, r"J'._____---......_— ❑Sanitary permits <br /> , <br /> CSM: LOT SUBDIVISION B.c,cwi.o T (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> �y 1 1J tb C Y.._.I'.._syte _......._._— ❑ Zoning District <br /> TQ� IJSx.�"� ��_��il�._._*.. (`ebwti .....—._ (viz �. <br /> . ❑This project is a new building or structure. ❑ Permitted Use <br /> 54This project is an addition/alteration to an existing building or structure. <br /> .._.._ <br /> SANITARY SERVICE' PERMIT ❑Rural Address ERMIT Ni1M8ER <br /> DEWER ,_ l REPTIC `new/existing)• <br /> HEIGHT IN FEET NUMBER OF STORIES- (Not indutling basement) <br /> 0 Wetland/Floodplain/ <br /> —1 _..---....._._—.—. Shoretand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT: I 1ST FLOOR T <br /> 2�.J S j,TOTAL SQUARE FOOTAGE: ,�. (Slopes,disturbance. <br /> 7 - filling/access) <br /> 2ND FLOOR: 3RD FLOOR , ktt J St_ <br /> _ ( U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q �S'Ooo and available options. <br /> (Please round to nearest dollar) �P I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Wes lNo QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes Do []Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes D Io <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eves E io <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) Eyes fNo QDon't know <br /> 7. Is this to correct a violation? Elves (llo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -+ <br /> 45.'t2;412$: <br />