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• PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME .--------- <br /> • <br /> Daniel e 01440 J /Uk S D Zoning Status;CUP; <br /> OWNER ADDRESS (Number.Street,City.State,Zip) xDeed Restriction; CSM <br /> 360 c,,,A,„t'y pr&m-u) eY k' owAlmI WZx..7,3V Variance(# ) <br /> HOME PHONE !CELL PHONE E-MAIL ADDRESS � <br /> `` i I I_ 0 Some -"h i,s f' obto e/` c�)OrmAif � 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTI ACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [l Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Lip) -' E Setbacks <br /> PHONE PHONE 0 Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> C Floor plans to scale <br /> PROPERTY/LOCATION"INFORMATION (bttpti/accossdane.co.dene,wt.usi) u Elevation of property <br /> PARENT PARCEL NUMBER: CURRE ZONING. ACREAGE: ( age drawn to scale. <br /> El <br /> NUMBER OSI\17d79_��609 3 r� 35:O 1 <br /> 'TOWNS SEC i ` way permits <br /> tu <br /> N Kk YZK ��°' A � ,A: C Drive(state,county, town) <br /> ADDRESS: 696E 7 _ j r 5?,5J9 1-1 <br /> ry <br /> 3 oa c �U�* 1-11,41, Al u /(J,� or 7 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 1 M 14 ' Pro' ,.� - <br /> A i ILO . LP /►t�t _Joni ) `Sid R —R1. �'t /I ❑ Zoning District <br /> . Ditfhis projec is a new building or structure. ❑ Permitted Use? <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> PERMIT NUMBER: — 13 Rural Address <br /> SANITARY SERVICE. (new/existing) <br /> �EVs'ER op-1-10 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ❑ 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) ❑ ErosionControl permit <br /> BASEMENT' 1ST FLOOR - disturbance, <br /> j TOTAL SQUARE FOOTAGE: j (slopes, <br /> 5� filling/access) <br /> 2ND FLOOR 3RD FLOOR O O M <br /> 0,5 Vj <br /> U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �D OBD 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? ........... PKIYes ONo ®Don't know <br /> 2. Is there a wetland or floodplain on or near the property? NYesRN0 <br /> ❑Dont know <br /> 3. Have you talked with the township about your project and are they in agreement? �'esNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes a 0 . <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 ai0 (JDon't know <br /> 7. Is this to correct a violation? ❑YeslO <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ —. —. <br /> SE',((1119) <br />