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IYANE COUNTY ZONING DIVISION <br /> CITY COUNTY BUILDING,RM 116 <br /> 210 MARTIN LUTHER KING,JR.BLVD. k' <br /> MADISON,WISCONSIN 53703-3342 �,�' <br /> PHONE 266-4266 FAX 267-1540 <br /> www.co.dane.wi.us <br /> ZONING PERMIT CHECKLIST <br /> ' K r� s.k\A, <br /> 1. LANDOWNER: 'Kr S b\.- v Crva V\r P&U i Hv5 k t S AGENT: C e I I 3 33-3$9(D <br /> ADDRESS: Let,nc, ADDRESS: <br /> I�01%vrcR�, w�. S353)- <br /> PHONE: (■09• M/•I-U - M 31 PHONE: <br /> EMAIL: U)A EMAIL: <br /> 2. DESCRIPTION OF PROJECT: I✓C c C x I Co <br /> ESTIMATED COST OF CONSTRUCTION: $ *500 .00 (Structure plus mechanicals.) <br /> 3. ADDRESS OF PROJECT,IF KNOWN: $4.5-1 . D e. Forts-- W 2 . 5 3 S 31. <br /> 4. TAX PARCEL NUMBER(as listed in AccessDane or on tax bill: 0 d I 0 0 w ' 1 0 11 •O <br /> 5 LOCATION OF PROJECT: U 1 t'0∎,v ev L h _ he 10r CS-k, w z- 53531 <br /> TOWNSHIP,SECTION,1/4 1/4 1-Ow 1.7 0 1✓ W i,v VS0 L <br /> SUBDIVISION OR CSM#(Certified Survey Map),IF ANY: N U L.LA•N 0 Fi 4.L 05 <br /> LOT NUMBER,IF ANY: LOT 1 9 1 Q <br /> 6. ZONING DISTRICT: I)A v' b CD • <br /> 7. SITE PLAN: *A site plan must be drawn to scale showing the lot lines and lot dimensio , 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 /> 8. FLOOR PLANS AND ELEVATION VIEWS(front,*I copy of floor 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? P J I u Se we <br /> STATE SANITARY PERMIT NEEDED? Y /€l IF YES,PERMIT# <br /> APPROVAL NEEDED FOR ADDING BEDROOM OR>25%AREA? Y / N 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? Y / 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? Y/67) FLOODPLAIN? Y /D WETLANDS? Y /ON <br /> 12. TOTAL AREA OF LAND DISTURBANCE(Square feet) 298 S F <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 />