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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 /> Wisconsin Department of Administration <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑Zoning Status; CUP; <br /> 101 East Wilson,Madison,WI 53707 Deed Restriction; CSM <br /> HOME PHONE CELL PHONE Variance(# ) <br /> E-MAIL ADDRESS <br /> (608)267-0422 bill.napier @wisconsin.gov ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> J.P.Cullen&Sons, Inc. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 330 East Delavan Drive <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Janesville,WI 53546 <br /> PHONE PHONE ❑Site Plan approval from <br /> (608) 754-6601 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> scott.lewellin @jpcullen.com ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL y <br /> NUMBER �/O UZ ©Z°1 --� S�/� 1 frontage drawn to scale. <br /> TOWNSHIP: SECT! 1 <br /> E1o0ini rS 4 fps'e —Q '/4: 1/1/; ❑Driveway permits <br /> ADDRESS: J (state,county,town) <br /> 201 South Dickinson Street Madison WI <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> State Archive Preservation Facility ❑ Zoning District <br /> 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 /> EWER 1EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI 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: Ertftsit?n(ii [O permit <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,'disturbance, <br /> / <br /> 2ND FLOOR: fillip access <br /> 3RD FLOOR: <br /> filling/access) <br /> ReviewLocation Survey: <br /> ESTIMATED CONSTRUCTION COST: and available D trys <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 ❑No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ODon'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? ❑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 EiVo ODon't know <br /> 7. Is this to correct a violation? [Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> Continue on Back) —► —► -+ <br />