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ZONING PERMIT APPLICATION .countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Kern Sarbacker/Koreen K. . uehn Trust <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> P.O. Box 44966, Madison, WI 53744 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)798-3258 (608)212-6780 jsarb @tds.net ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> William Keuler/Keuler Construction, Inc. Keuler Construction, Inc. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 8308 State Road 19 8308 State Road 19 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Cross Plains,WI 53528 Cross Plains, WI 53528 <br /> PHONE PHONE ❑Site Plan approval from <br /> (608) 798-1771 (608) 798-1771 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> keulerconstruction @hotmail.com keulerconstruction @hotmail.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 01'x''7 3 0 ',5 003 A_��X /-{V frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Berry 'A: 1/1/: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 9274 Kahl Road, Black Earth, WI 53515 <br /> CSM: LOT SUBDIVISION BLOCK/LOT E](public, permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Remodel/Addition ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> CSI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWERPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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 /> BASEMENT 1S LOQR: ❑ ErosionControl permit <br /> + TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> eG filling/access) <br /> 2ND FLOOR: J V L/3RD FLOOR: L <br /> 7 / ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST• --► ♦ ♦ ♦ ♦ ♦ $ a/ / Li i_/7 and available options. <br /> Please round to nearest dollar) �! / `�i <br /> 1 <br /> 1. The property is within 300 feet of a stream or 10 0 feet from a pond or lake? ❑Yes ❑✓No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the pr perty? ❑Yes ✓EN° ❑Don't know <br /> 3. Have you talked with the township about your pr ject and are they in agreement? ❑Yes ✓❑No <br /> 4. Has there been a zoning permit issued for this pr perty in the past 5 years? ❑Yes ✓Nlo <br /> 5. Is this project associated with a rezone/CUP/vari nce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) []Yes ❑No tgDon't know <br /> 7. Is this to correct a violation? ❑Yes ON <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -+ -i <br /> 545-112(4/08) <br />