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ZONING PERMIT APPLICATION www.countyofdane.com Fir=1213:22721C111, <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Jay Gould <br /> EiZoning Status; CUP: <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 5655 Lincoln Rd,Oregon WI Variance (# 10095 1 <br /> HOME PHONE CELL PHONE 1E-MAIL ADDRESS <br /> (608)835-2654 R'Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Tom Jones Tom Jones Company Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 148 Onyx Ct,Oregon WI 148 Onyx Ct,Oregon WI <br /> i <br /> (City,State,Zip) iCity,State,Zip) Q Setbacks <br /> Oregon,WI 53575 Oregon,WI 53575 <br /> PHONE PHONE ❑Site Plan approval from <br /> (608) 695-0828 (608) 695-0828 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tomjonescompany @gmail.com tomjonescompany @gmail.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 050907285309 A-2 5.07 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION ❑ Driveway permits <br /> Town of Oregon 1 a; 1/U q; <br /> ADDRESS: (state, county,town) <br /> Lot 3 , Crestwood Drive C'Zi I 1Q• °clp <br /> CSM l LOT !SUBDIVISION BLOCK'LOT ❑Sanitary permits <br /> 3 I (public, private) <br /> PROPOSED PROJECT INFORMATION -* <br /> PROJECT DESCRIPTION. <br /> Construction of a new home 0 Zoning District <br /> . 0 This project is a new building or structure. Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER ❑ Rural Address <br /> FIEWER [EPTIC �) <br /> HEIGHT IN FEET !NUMBER OF STORIES: (Not including basement: <br /> 28.7 1 1.0 Q a i_. ti `+•,• ainl <br /> — Shor P►, • (attachment)• <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR Li ' •' ° • trot permit <br /> 3,196.0 3,875.0 j TOTAL SQUARE FOOTAGE: j �s.4- r. '• Urbane, <br /> 2ND FLOOR 3RD FLOOR: 1 filling/access) <br /> 3,875.0 `4! ReviviLocation Survey <br /> ESTIMATED CONSTRUCTION COST: and available tions. <br /> (Please round to nearest dollar) —• —• —• —• —• 4 $ 250,000.00 oP <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes j� o QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes p2 o 0 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) Elves o is Don't know <br /> 7. Is this to cor reci;a violation? ❑Yes ✓No <br /> 3∎42%L G2 Pia <br /> SV-15 ;' APPLICATION MUST BE SIGNED <br /> sa,',>ra/oa <br /> b'? I (Continue on Back) <br />