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DANE COUNTY ZONING PERMIT CHECKLIST <br /> 210 Martin Luther King Jr.,Blvd.,Room 116 Madison,WI 53703(608)266-4266 <br /> 1. LANDOWNER: TO Lt)et 0 4 D V t KtR K AGENT: P24 ' &( .g <br /> ADDRESS: (g S Lf C i' .f/ ADDRESS: <br /> Silliffiliti. £42i 5395 <br /> PHONE: $73—CI i 1'' PHONE: <br /> EMAIL: EMAIL: <br /> 2. DESCRIPTION OF PROJECT: 'ye �y{�+,^cty[, Bu(CD rnC. <br /> v <br /> ESTIMATED COST OF CONSTRUCTION: $ c/51, &co (Structure plus mechanicals.) <br /> 3. ADDRESS OF PROJECT,IF KNOWN: (c 5 q C t N 5.10(5 G11i LA-1i <br /> 4. TAX PARCEL NUMBER(as listed in AccessDane or on tax bill: 0 (o/Q 5 f f —.02/3 —85 S'—3 <br /> 5 LOCATION OF PROJECT: <br /> TOWNSHIP,SECTION,1/4 1/4 ,D VII KI R IC , /V W Yil of S W 4 1 0 c Sec- (A117,5/1, I . 11 E. <br /> SUBDIVISION OR CSM#(Certified Survey Map),IF ANY: <br /> LOT NUMBER,IF ANY: <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 /> _ <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 location survey if you are with/n 10'of a required setback. <br /> ' <br /> 8( FLOOR PLANS gI1D ELEVATION VIEWS(front,*1 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? ?f I vet f e 3 ep4-t C S r S kf rA <br /> STATE SANITARY PERMIT NEEDED? DY IN IF YES,PERMIT# <br /> APPROVAL NEEDED FOR ADDING BEDROOM OR>25%AREA? ❑Y ON IF YES,PROVIDED? ❑Y ON <br />/�� (approval letter from Dane County Environmental Health-608.242.6515) <br /> 10. �11.DRIVEWAY(or Culvert or Access)PERMIT NEEDED? ❑Y ON IF YES,PROVIDED? DY ON <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 /> apSHORELAND? V WIN FLOODPLAIN? ❑Y N WETLANDS? ❑Y N <br /> 12. 11 :1T2Ir 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 /> *lt <br />