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DANE COUNTY ZONING • ERMIT DCPZP 2015-00623 Page oft OWNER INFORMATION AGENT/CONTRACTOR INFORMATION OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE DAKOTA J GRAY (608)247-11141 BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) 724 WASHINGTON RD (City,State,Zip) (City,State,Zip) EDGERTON, WI 53534 E-MAIL ADDRESS E-MAIL ADDRESS PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 0512-192-9110-3 TOWN OF ALBION 19 NW SW PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE (Assignment of new address is 724 WASHINGTON RD subject to field verification.) LOT BLOCK C.S.M.Na.or PLAT NAME 1 CSM 02059 ZONING DISTRICT PARCEL ACREAGE PROPOSED•ROJECT: New Structure/Addition CENSUS CODE R-1 Residence 0.71 Description:s -d 438-Garage District Category ® Residential ❑ Commercial ❑ Agri Itural SEWER SANITARY PERMIT NO ❑ Other: Private ROAD CLASSIFICATION REZONE NO C.U.P.NO VARIANCE NO. DEED RESTRICTION C-Town Road 6070 ❑ YES ® NO SHORELAND FLOOD ZONE WETLAND EC/SW NO. ❑ YES ® NO ❑ YES ® NO ❑ YE.. ® NO HEIGHT(In Feet) BASEMENT 1 1st FLOOR TOTAL SQUARE FEET 600 13.0 Sq.Ft. Sq.Ft.600 PROJECT COST NO OF STORIES 2nd FLOOR 3rd FLOOR $4,000.00 1 Sq.Ft. Sq.Ft. PERMIT FEE $95.00 I, the undersigned, am the owner of the prope y or an authorized agent acting on behalf of the owner of the property. I certify that the work to be perf•rmed, as part of this zoning permit, will be constructed as noted on the submitted plans and comply with the applicable zoning ordinances. I understand that failure to comply with any provision or condition of this permit renders this zoning permit null and void and subject to enforcement action. I acknowledge that I am responsible for complying with State and Federal laws concerning construction near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to identify. Failure to comply may result in removal or modification of construction that violates the law or other penalties or costs. For more information, visit the Department of Natural Resources web page at www.dnr.state.wi.us or contact the Department of Natural Resources Service Center. I hereby consent to the entry on the permitted premises by Dane County zoning inspectors for the purposes of determining compliance with the zoning ordinances. - Owner&Agent hereby agree to comply with all Dane County SIGNATURE: Owner/Agent DATE: Ordinances.Any unauthorized change from the information or plans submitted will invalidate the permit. G j • -1S OFFICE USE ONLY (form version 03.00.07) SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS 08/12/2015 SSA1 11 YES ❑ NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS Initials: