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DANE COUNTY ZONING PERMIT ZONING PERMIT NO. <br /> Page lof2 <br /> DCPZP-2015-00057 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> TOM & RENATHOMPSON (608) 837-3738 ALAN MOTL (608)655-4257 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 119 VINE ST 982 CANAL RD <br /> (City,State,Zip) (City,State,Zip) <br /> SUN PRAIRIE, WI 53590 MARSHALL, WI 53559 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tomandrena @yahoo.com avmotl @aol.com <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0812-042-9030-0 TOWN OF MEDINA 4 NW SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 6266 COUNTY HIGHWAY TT <br /> subject to field verification.) <br /> LOT BLOCK f C.S.M.NO.or PLAT NAME <br /> 1 I CSM 11496 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-1 Rural Homes 2.13 Description:sfr with deck 101 -SFR (detached) <br /> District . <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> Private 13-2015-00030 <br /> 0 Other: <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> B-County Highway 9216 ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> 0 YES ® NO ❑ YES ® NO ❑ YES ® NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 5822 <br /> 19'10" Sq.Ft.2171 Sq.Ft.3651 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $242,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $486.65 <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 SIGNAT.R : Ow. = A. • . DATE: <br /> Ordinances.Any unauthorized change from the information or / �� PIP,/ i /3,'/5 <br /> plans submitted will invalidate the permit. m/y A / <br /> OFFICE USE ONLY (form version 03.00.07) , <br /> SURVEY REQUIRED 7 DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 02/13/2015 SSA1 <br /> ❑ ES A ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: i i <br />