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DANE COUNTY ZONING PERMIT ZONING PERMIT NO. Page 1of2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> JASON L GUERIN THOMAS W MATSON (608) 873-0500 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 221 BREWSTER DR P.O. BOX 333 <br /> (City,State,Zip) (City,State,Zip) <br /> STOUGHTON, WI 53589 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tmatsonhomes.com <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0512-054-7057-0 TOWN OF ALBION 5 SE SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 1094 ELDON WAY <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 27 BLUE MEADOW ESTATES <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> R-1 Residence 0.59 Description:single family residence and screen porch 101 -SFR (detached) <br /> District <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> ❑ Other: Private 13-2015-00199 <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> E-AII Other 8383 <br /> ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> ❑ YES ® NO ❑ YES ® NO ❑ YES ® NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 4343 <br /> 30 Sq.Ft. 1743 Sq.Ft.2600 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $250,000.00 <br /> Sq.Ft. Sq.Ft. <br /> PERMIT FEE <br /> $375.72 <br /> I, the undersigned, am the owner of the property or an authorized agent acting on behalf of the'owner of <br /> the property. I certify that the work to be performed, as part of this zoning permit, will be constructed as <br /> noted on the submitted plans and comply with the applicable zoning ordinances. I understand that failure <br /> to comply with any provision or condition of this permit renders this zoning permit null and void and <br /> subject to enforcement action. <br /> I acknowledge that I am responsible for complying with State and Federal laws concerning construction <br /> near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be <br /> difficult to identify. Failure to comply may result in removal or modification of construction that violates <br /> the law or other penalties or costs. For more information, visit the Department of Natural Resources web <br /> page at www.dnr.state.wi.us or contact the Department of Natural Resources Service Center. <br /> I hereby consent to the entry on the permitted premises by Dane County zoning inspectors for the <br /> purposes of determining compliance with the zoning ordinances. <br /> Owner&Agent hereby agree to comply with all Dane County SIGNATURE: !dater/77C T DAT- ' <br /> Ordinances.Any unauthorized change from the information or <br /> O plans submitted will invalidate the permit. -`W Z/' / <br /> OFFICE USE ONLY (form version 03..00.07) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE I ITIALS <br /> 06/26/2015 SSA1 <br /> ® YES ❑ NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: <br />