Laserfiche WebLink
SUPPLEMENT to Web-App Si <br /> ZONIN PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA E <br /> Roger Thomas <br /> j <br /> Zoning Status; CUP; <br /> OWNER (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 10096 Spri g Valley Drive, Mount Horeb,WI,53572 V_rlanCe(# ) <br /> HOME PHON CELL PHONE E-MAIL ADDRESS <br /> (608)469-3931 rthomas @roadrunner.com 0 `to Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION -nd includes dimensions <br /> AGENT NAM: CONTRACTOR NAME <br /> Ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zi ) (City,State, ' ) Wetbacks <br /> PHONE PHONE ❑Site Plan -..proval from <br /> appli .• et. nship. <br /> E-MAILADDR SS E-MAIL ADDRESS <br /> Flo• plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 0 lev On of property <br /> PAREN PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> IN PARCE 0506-101-8500-5 Al e,c 34.10 f o age drawn to scale. <br /> NUMBE' <br /> TOWNSHIP: SECTION: <br /> Perry 10 1/4; NE 1 IA: El Drive permits <br /> ADDRESS: (st ,c unty,town <br /> 0096 Spring Valley Drice / <br /> Igl CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits J <br /> t (public,private) '----..kv0 <br /> PROPOSED PROJECT INFORMAYIOII STAFF REVIEW <br /> PROJECT DE.CRIPTION: ST/'C A• • h <br /> Alteration 1 emove wing,add back,replace bathroom, kitchen, new bathroom,vestibule). LI-Z I g District <br /> . ❑This p oject is a new building or structure. rmitted Use? <br /> 0 This p loject is an addition/alteration to an existing building or structure. <br /> SANITARY S='"VICE: PERMIT NUM ER: <br /> S Rural Ar.:,,`s <br /> 'FEWER rEPTIC (new/-xisting <br /> HEIGHT IN F:ET ' NUMBER OF S DRIES: (Not including basement) <br /> 2.0 <br /> e -nd loodplain/ <br /> or- . : attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> �� <br /> (Outside di ensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMEN 1STFyop�: — Url ErosionControl per `-c <br /> ( 1,� I TOTAL SQUARE FOOTAGE: ,, (slopes,disturbarf <br /> 2ND FLOOR: ' 3RD FLOOR: <br /> SSG <br /> filling/access) <br /> eview Location Survey <br /> ESTIMAT II CONSTRUCTION COST: Q and available options. <br /> (Please ro nc to nearest dollar) ♦ ♦ ♦ ♦ ♦ $ I-.-S K p \ <br /> 1. The pro.erty is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ❑No ❑Don t know <br /> 2. Is there : wetland or floodplain on or near the property? ❑✓Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes ❑No <br /> 4. Has the e been a zoning permit issued for this property in the past 5 years? Dies 4No <br /> 5. Is this p oject associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a loc- idn survey required? (see reverse) [Yes ONo EDon't know <br /> 7. Is this t. correct a violation? [Yes ONo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ♦ -► <br /> 545-112(4/08) <br />