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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 /> Jason L. & Sheila Guerin <br /> El Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 221 Brewster Dr.,Lake Mills,WI 53551 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> p Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Thomas W.Matson Matson Custom Homes, Inc. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> P.O.Box 333 P.O.Box 333 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Stoughton,WI 53589 Stoughton,WI 53589 <br /> PHONE PHONE <br /> ❑Site Plan approval from <br /> (608) 873-0500 (608) 873-0500 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tmatson @matsonhomes.com tmatson @matsonhomes.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 /> O PARCEL 002/0512-054-7057-0 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Albion 1/a: W/<. ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> /64i y Eldon Way <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> 27 Blue Meadow Estates (public,private) <br /> PROPOSED PROJECT INFORMATION *ROVIEW <br /> PROJECT DESCRIPTION: <br /> NEW SFD ❑ Zoning District <br /> . O This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ RuralAdt RuralAddress <br /> 1)EWER [EPTIC 13,201 ,500,199 (new/#Ming) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErO_„,.. orltr� Permit <br /> BASEMENT: 1ST FLOOR: <br /> ) `13 Z/''ro j TOTAL SQUARE FOOTAGE: ,l (slopes, <br /> 2ND FLOOR: 3RD FLOOR:l filling/ ) <br /> if L1 3 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available opti{options. <br /> (Please round to nearest dollar) -♦ -' .- .. -+ .- $ 250,000.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ✓No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Des jNo ❑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 ONo <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes ✓jNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />