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DANE COUNTY ZONING PERMIT DCPZG PERMI-00452 Page 1 of 2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE f AGENT/CONTRACTOR NAME PHONE <br /> GREGORY JONES 608-220-314 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 10804 KINGSLAND RD <br /> (City,State,Zip) (City,State,Zip) <br /> BLUE MOUNDS, WI 53517 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> GJONES @DAVEJONESINC.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0606-202-8020-0 TOWN OF BLUE MOUNDS 20 NW NE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 10804 KINGSLAND RD <br /> subject to field verification.) <br /> LOT BLOCK I C.S.M.NO.or PLAT NAME <br /> 1 CSM 09779 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-4 Rural Homes 17 Description:RES ACCESSORY BUILDING 50X80 329-Other <br /> District <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> ❑ Other: Private <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> C-Town Road 10987 <br /> ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> ❑ YES ® NO 0 YES ® NO 0 YES ® NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 17.8 Sq.Ft. Sq.Ft.4000 <br /> 4000 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $100,000.00 <br /> Sq.Ft. Sq.Ft. <br /> PERMIT FEE <br /> $350.00 <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: Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. P Af 7/21/I V <br /> OFFICE USE ONLY (form version 03.01.00) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 07/21/2016 HJH3 <br /> U ES ® NO <br /> �/", DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: 7-a.1 - /G Qm t/ <br />