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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Joseph M. Klimczak [Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2874 Lakeside St., Madison, WI 53711 Variance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> (608)437-3038 (608)345-3039 joe @caveofthemounds.com s-Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Joseph M. Klimczak Same []"Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2874 Lakeside St. <br /> (City,State,Zip) (City,State,Zip) f Setbacks <br /> Madison, WI 53711 <br /> PHONE PHONE Site Plan approval from <br /> (608) 437-3038 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> joe @caveofthemounds.com [Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ®'Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 0606-082-8780-0 RH1 2.95 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ,-�/ <br /> Blue Mounds 8 1/4: NW 1/41/4: NW Et Driveway permits <br /> ADDRESS. 2963 Cave of the Mounds Rd, Blue Mounds, WI 53517 (state,county,town) <br /> Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 11 ,578 3 na na (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Addition to single family residence ❑ Zoning District <br /> ['This project is a new building or structure. <br /> ❑ Permitted Use? <br /> 12 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1-3 7•,16I',,, ❑ Rural Address <br /> EWER EPTIC I' 93- C v (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) t <br /> 22.0 1.0 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinish-- _ -. _ ..es and above grade decks or porches) <br /> BASEMENT: 1 FLOOR: <br /> ❑ ErosionControl permit <br /> I ` /2. 5F y TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> zN. _ ��R: D filling/access) <br /> E? 6 5F 0E016 QQ ( <br /> � �© � ❑ Review Location Survey <br /> COST: QQ�� <br /> and available options. <br /> (Please round to nearest dollar) ♦ ♦ "'r ♦ ♦ "+ .p 50,000.00 <br /> p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes t2 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes al No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑✓Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ❑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) ❑Yes tg No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 12 No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4:081 <br /> (Continue on Back) —► —► <br />