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Z i 7 t.1 ji 4 7 ( <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Kwik Trip Inc <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,Stale,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 ❑Site Plan approval from <br /> (608) 781-1450 (608) 781-1450 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> cindyb @lacrossesign.com clndyb @lacrossesign.com ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.wi.us!) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: 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 1/41/4: NE ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 4112 Milwaukee St <br /> CSM: 11 449 LOT 1 SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAEF.REVIEW <br /> PROJECT DESCRIPTION: TV/ I' '/ t A (0 / /(, A <br /> Signs for new Kwik Trip at former PDQ.PI-ase se- attached sig site plan a • artwork.` 0 Zoning IDistnct <br /> This project is a new building or structure. Permitted tJse <br /> NI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rtd1 1Address <br /> EWER JEPTIC n1 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI Wetland/Floodptath/ <br /> horeland; attacbrr ent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: Eros)onControtperrrut <br /> ;� 4, TOTAL SQUARE FOOTAGE: j* (slOpesa dIstur"bance� <br /> 2ND FLOOR: 3RD FLOOR: �� fliilnQ/2CC£SS <br /> l ` Q ReVlew Lo att©n a�O.NOy <br /> ESTIMATED CONSTRUCTION COST: ancf avatlableOptlOrlS <br /> (Please round to nearest dollar) ♦ -' ♦ ♦ ♦ ♦ $ 41,700.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑✓No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [ales io ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Des ❑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) ❑Yes INo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes riNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -+ <br /> 545-112(4108) <br />