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DANE COUNTY ZONING PERMIT CHECKLIST <br /> 210 Martin Luther King Jr.,Blvd.,Room 116 Madison,W 53703(608)266-4266 <br /> 1. LANDOWNER: �Ceq ("P.r cI AGENT: Ian 'i: t Q S LLC <br /> ADDRESS: //`/l &Ood I0. I lk 2c4 - ADDRESS: -75 7l Col.(e.r ( <br /> cI So'), Luz 5-37/l e-Mr-e-s4- t w= 53S32_ <br /> PHONE: (oOg-S'1 S'03 Z q PHONE: (DO$ cz4 ' 3I Lt <br /> EMAIL: ctnd 3(9 €ra. COAA EMAIL: (to begi n J ,. (ders.c_oAA <br /> 2. DESCRIPTION OF PROJECT: Ackk, S t - ley e I <br /> ESTIMATED COST OF CONSTRUCTION: $ /07 0/000 (Structure plus mechanicals.) <br /> 3. ADDRESS OF PROJECT,IF KNOWN: 91-11C1 600c1 c 6d <br /> 4. TAX PARCEL NUMBER(as listed in AccessDane or on tax bill: S G G/0l 0 q2 -63' 3" / <br /> 5 LOCATION OF PROJECT: or '6,.., (\ () <br /> TOWNSHIP,SECTION,1/4 1/4 0 N t U E 02 /J W sc A-SSQ.t-Co,y P(c * <br /> SUBDIVISION OR CSM#(Certified Survey Map),IF ANY: <br /> LOT NUMBER,IF ANY: gI ac,K <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? <br /> STATE SANITARY PERMIT NEEDED? ❑Y N 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. 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? BAN FLOODPLAIN? ❑Y ON WETLANDS? ❑Y❑N <br /> 12. TOTAL AREA OF LAND DISTURBANCE(Square feet) /S-00 <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 />