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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 /> Kwik Trip Inc ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 1626 Oak St/PO Box 2107 La Crosse WI 54602 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)793-5913 rroberts @kwiktrip.com ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> La Crosse Sign Group La Crosse Sign Group ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2242 Mustang Way(home office 1450 Oak Forest Dr Onalaska WI) 2242 Mustang Way <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Madison WI 53718 Madison WI 53718 <br /> PHONE PHONE LI Site Plan approval from <br /> (608) 781-1450 (608) 781-1450 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> cindyb @lacrossesign.com cindyb @lacrossesign.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 008/0710-041-4160-0 C-1 DCPREZ-0000-09858 1.24 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Town of Blooming Grove 4 1/4. SW 1/41/: NE ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 4112 Milwaukee St <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> 11,449 1 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Signs for new Kwik Trip at former PDQ.Please see attached sign site plan and artwork. 0 Zoning District <br /> . ['This project is a new building or structure. 0 Permitted Use? <br /> 4 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rura-lAddress <br /> EWER r)EPTIC (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: 1ST FLOOR: 0 ErosionContro)permit <br /> TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling /access) <br /> 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and'available A bogs. <br /> (Please round to nearest dollar) --. ♦ -' -+ -► -4 41,700.00 p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des 'ANa ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes laio ❑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? QYes ❑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 Oro ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ✓❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -+ <br /> 545-112(4108) <br />