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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUS ' a MER TO PROVIDE <br /> OWNER NAME <br /> Dane County 1 <br /> Ly Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State.Zip) Deed Restriction; CSM <br /> 210 Martin Luther King JR Blvd, Room 114,Madison WI 53703 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> is Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Chris James McKee Associates, Inc. <br /> 12 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5201 Fen Oak Dr, Room 208 925 Watson Ave / <br /> (City,State,Zip) (City,State,Zip) Q Setbacks <br /> Madison,WI 53718 Madison,WI 53713 .■ <br /> PHONE ❑(608) 224-3763 PHONE (608) 271-4900 appl at5(e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> james@countyofdane.com 12 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi-us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Ed <br /> ❑PARCEL 004/0807-111-8000-0 A-1 (EX) 41.00 frontage drawn to Scale. <br /> NUMBER / <br /> TOWNSHIP: SECTION: -'' <br /> Berry 11 1/a: NE 1/41/4: NE ❑D ewa pe`rmlt5 <br /> •ADDRESS: <br /> tat ounty,town) <br /> 8183 State Hwy 19, Cross Plains, WI 53528 <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION '' TAFF=REVIEW..:'' `"'< <br /> PROJECT DESCRIPTION: / i/L/ <br /> Indian Lake Restroom Facility 3 0 x 7 ! EU, oning District <br /> . IN This project is a new building or structure. Permitted Use? C <br /> ['This project is an addition/alteration to an existing building or structure. ' <br /> SANITARY SERVICE: PERMIT NUMBER' Ural S . <br /> FTEWER /IEPTIC 1,2 --J0 162 ~ a 0 J vS V <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 22.0 1.0 JewfçnY <br /> etlaoodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorela>td (attachment) ' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: Et'oSionGontralpermit <br /> —0.0-1. /3)0 4 TOTAL SQUARE FOOTAGE: lopes disturbance, <br /> tiling/access} <br /> 2ND FLOOR: 3RD FLOOR: 1•it� 0 S Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options.' J <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ $ 240,000.00 . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes ❑No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑✓Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? QYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years?' :Yes 1g 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 ©No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes '4No <br /> . APPLICATION MUST BE SIGNED <br /> (Continue on Back) , —► -i <br /> 545-112(4/08) <br />