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ZONING PERMIT APPLICATION www.countyofdane.com F <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Kirk Everson C Zoning Status;CUP; <br /> O;:VNER ADDRESS (Number,Street.City,State.Zap) Deed Restriction;CSM <br /> N8545 Ridge Rd Van Dyne WI 54979 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILVDRESS <br /> (9 20)979-1259 (Lf,L �-J -&-- Z ' t/Y�A1 11corr1 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATIGN and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Matter Construction Services LLC 9 <br /> __ — Site Plan including location <br /> AGENT ADDRESS _.._.......... CONTRACTOR ADDRESS _ ..._...._.__ of well/septic <br /> W1268 Cty Rd S <br /> (City,State.Zip) j(City.State,Zip) Setbacks <br /> Kewaskum WI 53040 <br /> PHONE `PHONE — -� ' 0 Site Plan approval from <br /> (920) 979-3123 applicable township. <br /> • <br /> E-MAIL ADDRESS i E-MAIL ADDRESS <br /> ericmatter12Qgmail.com C Floor plans to scale <br /> • <br /> PROPERTY/LOCATION INFORMATION (http:ltaccessdane.co.dane,wl.us/) Elevation of property <br /> PARENT 'PARCEL NUMBER CURRENT 2 I G ;ACREAGE <br /> PARCEL frontage drawn to scale. <br /> ,— i±li)MBER � g <br /> TOWNSHIP: SECTION: <br /> . , ' E Driveway permits <br /> Cottage Grove i 4 Ys: J;/� <br /> __..__ (state, county,town) <br /> ADDRESS: <br /> 4721 Gaston Circle <br /> _�-_._.-._..._.___..._._. ❑Sanitary permits <br /> cm 6,734 LOT 1 ISUBOMMMSION —____........_.._.?.BL000K/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Rebuild burned down home on existing foundation i Zoning District <br /> . (This project is a new building or structure. <br /> Permitted Use? <br /> is This project is an addition/alteration to an existing building or structure. <br /> SANITARY'SERVICE. ..).'PERMIT NUMBER __.-__-_.......___..._......_._.......—____..___ , Rural Address <br /> FIEWER (-)cPTli. <br /> (new/existing) <br /> HEIGHT IN FEET: NUMBER OE STORIES' (Not including basement) <br /> 15.0 1.0 J 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 /> ..............__.__-- -_ ._._..........__.._....__..._......__ J ErosionControl permit <br /> BASEMENT: 15T FLOOR TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> 1 ,008.0 1,300.0 �. 3 <br /> __.._T filling/access) <br /> 2ND FLOOR 3RD FLOOR: 00.0 <br /> _._...._..\.._............_..__ _ 1 _......____.__...-___......_._......_.........._._. Li Review Location Survey <br /> ESTIMATED CTION COST: and available options. <br /> (Please round to nearest dollar) -► -. -r -. -. -. $ 140,000.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? f Yes ✓[ +lo nDon't know <br /> 2. Is there a wetland or floodplain on or near the property? f Yes o ✓jDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? : Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes Efrqo <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 nDon't know <br /> 7. Is this to correct a violation? Efres _✓[ INo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -- —. <br /> S45-1 12(408) <br />