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N <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Tara Pearson <br /> OWNER ADDRESS (Number,Street.City,State,Zip) ['Zoning Status; CUP; <br /> Deed Restriction; CSM <br /> 343 Lake Kegonsa Rd., Oregon, WI 53575 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)212-0081 (608)212-0081 tara @wiscompany.com Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Cleary Builders ['Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 190 Paoli St. <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Verona, WI 53593 <br /> PHONE PHONE ['Site Plan approval from <br /> (608) 845-9700 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> verona@clearybuilding.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: El <br /> ['PARCEL 0510-274-8005-0 A-1 Ex 38.00 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Rutalnd 27 1/4: SE 1/41/4: NE ['Driveway permits <br /> ADDRESS: (state,county,town) <br /> 343 Lake Kegonsa Rd. Oregon, WI 53575 sanity <br /> CSM: LOT SUBDIVISION BLOCIOLOT ['Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> New structure,Ag Building ❑ Zoning District <br /> . tg 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 (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not induding basement) <br /> 24.0 1.0 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT. 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> {, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 7,680.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --0. -1. -4. $ ..„..3 n i <br /> 0© () and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes ✓llo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes ✓ 10 ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? la es DIINo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 1=IYes ❑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 ElNo ['Don't know <br /> 7. Is this to correct a violation? Q✓Yes alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -4. -4. <br /> 545-112(4/09) <br />