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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 /> Chad & Lynn Kitsemble <br /> -0 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 205 Heather Court Mt.Horeb,WI 53572 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS / <br /> (608)445-9405 (608)354-8504 kitcl @mhtc.net ® Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION /and includes dimensions <br /> AGENT NAME CONTRACTOR NAME f <br /> Lynn Kitsemble [ i Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS 'Of well/septic <br /> 205 Heather Court <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> Mt.Horeb,WI 53572 Mt.Horeb,WI 53572 f <br /> PHONE (608) 354-8504 PHONE (608) ❑Site Plan approval from <br /> ,`alplicye township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / <br /> lynn.kitsemble @mounthorebwi.info 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn (Elevation p of property <br /> nPARENT PARCEL NUMBER: CURRENTZO ING: ACREAGE: <br /> 15 NUMBER <br /> NUMBER 0606-022-9680-0 ?� I C A a 4 frpntage drawn to scale. <br /> TOWNSHIP: SECT • ��---, it <br /> : r y41/4: JDriveway permits <br /> Town of Blue Mounds /a. \ vlanitary`tate,county,town) <br /> ADDRESS: 3 / 3 fl, \ 1'1 \ 0'�-L� <br /> CSM: LOT S BDIVISION BLOCK/LOT permits <br /> 900 f (public,private) <br /> PROPOSED PROJECT INFORMATION TAFF;REVIEW <br /> PROJECT DESCRIPTION: : `e t; <br /> Single Family Residence V3 C C�;,/� L°• • 114blstnct !kt '* <br /> y5' <br /> . 0 This project is a new building or structure. Y� 'f t g ' #i <br /> �er�tt d Use <br /> ['This project is an addition/alteration to an existing building or structure. 4 . �,;+" T , <br /> SANITARY SERVICE: PERMIT NUMBER: / Q ® Ural (]dress <br /> FIEWER PTIC / �' i2Of — 00 J 1 a f fi <br /> sx�z (new xlsting) <br /> HEIGHT IN FEET: [ NUMBER OF STORIES: (Not including basement) <br /> ,r <br /> �� horel ,attachment) : ) <br /> AREA TO NEAREST SQUARE FOOT: ' °>f " <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , ;� �Ar<*, .' �l <br /> BASEMENT: 1ST FLOOR: `. ErioslonControl permlt <br /> ; 'Z 9 cg0 j TOTAL SQUARE FOOTAGE 4 ''- (SlO�es,diturbance, I �� <br /> = fillln•/access) r'j <br /> 2ND FLOOR: 3RD FLOOR: K)K,i <br /> 0 �/ 0 Revie LOCati r S r ey <br /> ESTIMATED CONSTRUCTION COST: and,aVaa6�e OptlOf�S / <br /> (Please round to nearest dollar) -� '� • ,ems 4 , . �,1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes NI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 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? Des MINo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank tf none) <br /> 6. Is a location survey required? (see reverse) [Yes in No ❑Don't know <br /> 7. Is this to correct a violation? .1111 es JNo <br /> 4' APPLI I ATION MUST BE SIGNED <br /> 545-112(4/08) ��,, '' (Con ' ue on Back) -+ -► <br />