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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: he-erfr ✓ frU$.S AGENT: <br /> ADDRESS: K7/3z_ /,d_ron ADDRESS: <br /> /fawrrnte, )/ .5)S(AC) <br /> PHONE: Cga - 235- ?250 PHONE: <br /> EMAIL: - r)Gi t e f--ke-m ed EMAIL: <br /> 2. DESCRIPTION OF PROJECT: AA CZ 0 <br /> ESTIMATED COST OF CONSTRUCTION: � loOo (Structure plus mechanicals.) <br /> 3. ADDRESS OF PROJECT,IF KNOWN: /O93z f-Ud(SGY, ,' JV Q ZUrh4 nit W I S3 j co() <br /> 4. TAX PARCEL NUMBER(as listed in AccessDane or on tax bill: 0310 go(p^07.7 ?GeV--0 <br /> 5 LOCATION OF PROJECT: /09:30- `/uxikTi I1' -41'74J1(e ( .5 SS?di <br /> TOWNSHIP,SECTION,1/4 1/4 -7-09 <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 /> 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 within 10'of a required setback. <br /> 8. FLOOR PLANS AND 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? Pr <br /> STATE SANITARY PERMIT NEEDED? ❑YWIN IF YES,PERMIT# <br /> APPROVAL NEEDED FOR ADDING BEDROOM OR>25%AREA? ❑Y®N IF YES,PROVIDED? ❑Y ON <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 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 /> 11. SHORELAND? 0Y4N FLOODPLAIN? ❑Y®N WETLANDS? ❑YELN <br /> 12. TOTAL AREA OF LAND DISTURBANCE(Square feet) <br /> �d6o <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 />