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DANE COUNTY ZONING PERMIT DCPZP 2016-00435 Page of <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> LARRY D HEIMAN LE (608)698-4165 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 331 FIR LN <br /> (City,State,Zip) (City,State,Zip) <br /> MARSHALL,WI 53559 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0812-162-9160-3 TOWN OF MEDINA <br /> 16 NW SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 1049 COUNTY HIGHWAY T <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 02803 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> A-1 Ex Exclusive Ag Description:40'x 28'x 13'ag stor shed 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 /> B-County Highway DCPZP-1980-02568 <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 /> 1120 <br /> 13 Sq.Ft. Sq.Ft.1 120 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $10,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $134.00 <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 subject <br /> 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 difficult <br /> to identify. Failure to comply may result in removal or modification of construction that violates the law or <br /> other penalties or costs. For more information, visit the Department of Natural Resources web page at <br /> 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 SIGNA E: Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. 7,- zO <br /> - <br /> OFFI.E USE ONLY (form version 03.01.00) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 07/15/2016 RLB <br /> ❑ YES NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials_ rn /!1 <br />