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DANE COUNTY ZONING PERMIT Page 1 of2 <br /> DCPZP 2014-00840 <br /> OWNER INFORMATION I AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME HONE <br /> RICKY R HELD (608)837-4633 y� Iii <br /> BILLING ADDRESS(Number,Street) ADDRESS(Numbel t <br /> 1560 STATE HIGHWAY 19 YYYYYY rt A <br /> (City,State,Zip) (City,State,Zip) �O\I <br /> 7 .1" 4()A <br /> MARSHALL,WI 53559 I <br /> E-MAIL ADDRESS E-MAIL ADDRESS , MG&O OPV <br /> PARCEL NO. TOWNSHIP ogNft0;31' 1/4 1/4 <br /> 0812-073-8530-0 TOWN OF MEDINA NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 1560 STATE HIGHWAY 19 <br /> subject to field verification.) <br /> LOT !BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 10993 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-2 Rural Homes Description:20'x 12'x 12'det salt 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 /> A-US or State Highway 8818 <br /> ❑ YES ❑ NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> ❑ YES 0 NO ❑ YES 0 NO YES ❑ NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 240 <br /> 12 Sq.Ft. Sq.Ft.240 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $3,600.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $68.00 <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 zonin• ordinances. <br /> . . . <br /> Owner&Agent hereby agree to comply with all Dane County SIGNATURE: 0. • / •nt DATE: <br /> Ordinances.Any unauthorized change from the Information or / <br /> plans submitted will invalidate the permit. . ° C <br /> OFFICE USE ONLY (form version 03.00.07) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 10/30/2014 RLB <br /> 0 YES ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials:�� t�iL� <br />