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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 /> George B Fink, Rev Trust n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM9674 Lee Valley Road, Blanchardville, WI 53516 <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 608-636-3361 geofmac@yahoo.com n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Tina Redington Premier Building Solutions n Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2581 Hwy 92 2581 Hwy 92, <br /> (City,State,Zip) (City,State,Zip) ❑✓ Setbacks <br /> Mt Horeb, WI 53572 Mt Horeb, WI 53572 <br /> PHONE PHONE Ti Site Plan approval from <br /> 608-630-1007 608-630-1007 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS Q Floor plans to scale <br /> tinar@premierbuildingsolutions.biz tinar@premierbuildingsolutions.biz <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: E Elevation of property <br /> n PARCEL 0506-252-9060-4 FP-35 20 frontage drawn to scale. <br /> NUMBER �A� <br /> TOWNSHIP: SECTION: mac+ v, �`C .,,`" <br /> Perry 25-5-6 1/q: vW ' 1/,: NW n Driveway permits NA <br /> ADDRESS: (state, county,town) <br /> 9674 Lee Valley Road, Blanchardville, WI 53516 <br /> CSM: LOT SUBDIVISION BLOCK/LOT Ti Sanitary permits �� L___,(public, private) _,,,) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Demo existing residence and rebuild residence U Zoning District <br /> . riThis project is a new building or structure. a Permitted Use? <br /> nThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rural Address <br /> EWER [EPTIC 13,202,100,180 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 20' 1.0 U Wetland/Floodplain/ V, G=.3 <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) rr�� <br /> BASEMENT: 1ST FLOOR: !U Erosion Control permit ,\ <br /> 2,317.0 4,077.0 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, , <br /> filling/access) --�, <br /> 2ND FLOOR: 3RD FLOOR: C 1 <br /> a:3i4 ,S <br /> 1' 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 720 255.00 and available options. } C <br /> (Please round to nearest dollar) Y v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes 4016 nDon't know <br /> 2. Is there a wetland or floodplain on or near the property? nYes .nNo nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? nYes 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 nNo nDon't know <br /> 7. Is this to correct a violation? LYes nNo <br /> (+.1 <br /> 1,'C, <br /> r.- <br /> t APPLICATION MUST BE SIGNED <br /> . (Continue on Back) —► -i <br /> REV(01/19) `J <br />