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TEM Cbeske4 CS-01-4*-- PeE - <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> UW Health <br /> ['Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 7974 UW Health Court Middleton,WI 53562 Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)828-8598 Jerry.McGuire @uwmf.wisc.edu ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> J.P.Cullen&Sons,Inc.from pEet-7J. Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 330 E.Delavan Drive <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Janeville,WI 53546 <br /> PHONE PHONE ❑Site Plan approval from <br /> (608) 754-6601 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS 0g -7 S I -5501 CEL{, <br /> tom.pertzborn @jpcullen.com ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZO NG: ACREAGE: <br /> ❑PARCEL <br /> NUMBER 0 d jp 1,3 .��°l Z frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 'A: '/4'/4: ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> 2-4 OZ ws jwc DAG-a _Sr, 64 kb>;Seivj.tJS 53701 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> go <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Union Corners Clinic ❑ Zoning District <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Z- z ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ —1. -0. ♦ ♦ ♦ �� and available options. <br /> (Please round to nearest dollar) <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? Lives ❑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 Elo ['Don't know <br /> 7. Is this to correct a violation? [Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ -♦ <br /> 545-112(4/08) <br />