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MAL <br /> DANE COUNTY ZONING PERMIT CHECKLIST <br /> 1 <br /> 210 Martin Luther King Jr.,Blvd.,Room 116 Madison,WI 53703(608)266-4266 <br /> ^ <br /> I. LANDOWNER: ✓ s. 4, ■:,„. •■ yeti AGENT: `( _ - • _) <br /> ADDRESS: 4110MMOir- ► ,/ ADDRESS: Y/11.141...17110 -/ <br /> 41a. so Mi ErvM.-Mfltr F <br /> PHONE: (9 z.) 29,' PHONE: COOS) 7V—4X94ri<,7 <br /> EMAIL: /'4,'elye O 3c i d.r. GtO•si EMAIL: j 1,yr1-J C/Abitrot-eons <br /> 2. DESCRIPTION OF PROJECT: /414//0.999(2? P7 /JO(.4.f/, 13'if"p, <br /> * <br /> ESTIMATED COST OF CONSTRUCTION: S 60)0(00. 00 (Structure plus mechanicals.) <br /> 3. ADDRESS OF PROJECT,IF KNOWN: /7(5—ifietarZD 1"R/i/e,. <br /> 4. TAX PARCEL NUMBER(as listed in AccessDane or on tax bill: OP/A /O 'QSW'04 esit -7 <br /> 5 LOCATION OF PROJECT: <br /> TOWNSHIP,SECTION,1/4 1/4 S„ A .•.:47, ... .Arr I -47. / <br /> SUBDIVISION OR CSM#(Certified Survey Map),IF ANY: 4/k;-ME?r7 asamtess <br /> LOT NUMBER,IF ANY: /44 <br /> 6. ZONING DISTRICT: <br /> 7. SITE PLAN: *A site plan must be drawn to scale showing the lot lines and lot dimensions,the location <br /> and size of all existing and proposed buildings or additions and their distances from <br /> lot lines. If the lot is not served by public sewer,the location and size of the on-site <br /> septic system and the location of the well shall be shown on the plan.Site plan must be signed and dated. <br /> Example of a site plan on back side of this form. <br /> Your permit may require a locution survey if you are within 10'of a required setback. <br /> 8. FLOOR PLANS AND ELEVATION VIEWS(front,*/copy offloor plans will be kept in the Zoning Department files. <br /> Examples of Floor Plans and Elevations attached �,. "_ <br /> 9. PUBLIC SEWER OR PRIVATE SEPTIC SYSTEM? /LMINSeAi M67to 50-blie& Z>isr <br /> STATE SANITARY PERMIT NEEDED? ❑Y[j'4 IF YES,PERMIT# <br /> APPROVAL NEEDED FOR ADDING BEDROOM OR>25%AREA? ❑Y[RN IF YES,PROVIDED? ❑Y❑N <br /> (approval letter from Dane County Environmental Health-608.242.6515) <br /> 10. DRIVEWAY(or Culvert or Access)PERMIT NEEDED? ❑YgiN IF YES,PROVIDED? ❑Y❑N <br /> Contact County Highway Department for County Highway Access Permits(608)266-4261. <br /> Contact DOT for access permits on State and Federal Highways(608)246-3800. <br /> *Towns requiring Driveway Permits are:Albion,Berry,Blooming Groove,Blue Mounds,Burke.Cottage Grove.Deerfield,Dunkirk, <br /> Dunn,Mazomanie,Montrose.Oregon,Perry, Pleasant Springs.Primrose,Roxbury.Rutland,Springdale,Springfield,Sun Prairie. <br /> 11. SHORELAND? ❑yE FLOODPLAIN? ❑Y1a'1Q WETLANDS? DYNIN <br /> 12. TOTAL AREA OF LAND DISTURBANCE(Square feet) <br /> *If disturbed area is greater than 4000 square feet.or is located near a lake,pond,river or stream you may need an erosion control <br /> permit. Please contact Land Conservation at(608)224-3730. <br />