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SUPPLEMENT to Web-App# <br /> w <br /> ZONING PERMIT APPLICATION ww.countyofdane.com i <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Gregory and Chelsie Ebert 0 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 414 N RIVERSIDE DR WATERLOO WI 53594 __ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (704) 657-0038 gregebert87@hotmail.com Q✓ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ambiance Homes Inc Ambiance Homes Inc ['✓ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5833 Grassland Terrace 5833 Grassland Terrace <br /> (City,State,Zip) (City,State,Zip) Q Setbacks <br /> Marshall, WI 53559 Marshall, WI 53559 <br /> PHONE PHONE Q Site Plan approval from <br /> (608) 225-4594 (608) 225-4594 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ambiancehomesinc@charter.net ambiancehomesinc@charter.net ❑✓ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 07-0091234195150 RR-2 2.21 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: Driveway 34 1/Q: SE 1/: NE ❑ permits <br /> ADDRESS: 6533 STATE HWY 73 (state, county,town) <br /> Highway 73 <br /> [✓]Sanitary permits 4 BR <br /> CSM: 15,652 I LOT 1 SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> Pew CTSi gle4 BEDROOMS W/ DECK AND SCREEN PO Rg o <br /> New Single family residence Hing District <br /> . ❑✓ This project is a new building or structure. ❑ Permitted Use? YES <br /> JThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: 1 PERMIT NUMBER: ❑ Rural Address NEW <br /> r)EWER FIEPTIC 13,202,100,128 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) NO <br /> 23.0 1.0 ❑ 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: p 1 ❑ ErosionControl permit <br /> 2,113.0 3 800,0 4, TOTAL SQUARE FOOTAGE: 4r (slopes,disturbance, EC 2021 <br /> 2ND FLOOR: 3RD FLOOR: filling/access) -0;25 <br /> 3,800.0 5913 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) -�► -�► '- -+ —' -♦ $ 400,000.00NO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves ❑ o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eves ✓['No QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [Yes QNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes IDNo <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 ✓ENo ['Don't know <br /> 7. Is this to correct a violation? Elves No <br /> $641.30 APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -♦ <br /> REV(01/19) <br />