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DANE COUNTY ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPZP-2015-00474 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> KERRI L KELLERMAN (608) 873-5678 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 3868 OLD STONE RD <br /> (City,State,Zip) (City.State,Zip) <br /> OREGON, WI 53575 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r.koutdoors2@gmail.com <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0510-223-9500-7 TOWN OF RUTLAND 22 SW SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST TYPE <br /> (Assignment of new address is 3868 OLD STONE RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO or PLAT NAME <br /> METES AND BOUNDS <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: Alteration to existing building CENSUS CODE <br /> A-1 Ex Exclusive Ag 25.6 Description:30x16 rear three season porch+10x16 rear deck 328- Other Non-Residential <br /> District addition <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 <br /> i <br /> / ❑ YES © NO <br /> SHORE(AND FLOOD ZONE WETLA D EC/SW NO. <br /> -. YES 0 NO Q YES ❑ NO ISYES 44,,NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 640 <br /> 12 <br /> Sq.Ft. Sq.Ft.640 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $6,000.00 <br /> 1 Sq.Ft Sq.Ft PERMIT FEE <br /> $98.00 <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 SIGNATU•E: Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. i��,- - �� �� /(n L9-01 pl „ (S <br /> OFFICE USE ONLY (form version 03.00.07) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> ❑ YES ® NO 06/29/2015 SJW3 <br /> DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: CO „ J 0 ,' ) P `l <br />