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DANE COUNTY ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPZP-2015-00690 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> FRANK SELTZNER (608)764-3115 Farwell Pools (608)222-1730 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 4 SAVANNAH PKWY 3818 County Highway AB <br /> (City,State,Zip) (City,State,Zip) <br /> DEFOREST,WI 53531 Madison,WI 53718 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0812-073-8850-0 TOWN OF MEDINA <br /> 7 SW NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address Is 1567 STATE HIGHWAY 19 <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 2 CSM 10993 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-2 Rural Homes Description:40'x 20'in grd pool 329-Other <br /> District <br /> Category ® Residential ❑ Commercial ❑ Agri cultural SEWER SANITARY PERMIT NO. <br /> Private <br /> ❑ Other. <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 /> 0 YES ® NO ❑ YES ❑ NO ❑ YES ❑ NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 800 <br /> 1 Sq.Ft. Sq.Ft.800 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $50,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $110.00 <br /> I, the undersigned, am the owner of the prope y or an authorized agent acting on behalf of the owner of <br /> the property. I certify that the work to be perf rmed, 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 th s 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. Wet�ands that are not associated with open water can be difficult <br /> to identify. Failure to comply may result in renoval 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 /> l <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 SIGN ' RE: OwneL Agent DATE: <br /> Ordinances.Any unauthorized change from the Information or [[l �j�� ` <br /> plans submitted will Invalidate the permit. ,-4.-%u�' l - /-S <br /> OFFICE USE ONLY (form version 03.00.07) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 09/01/2015 RLB <br /> /. D YES ® NO DATE REVIEWED . INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials'[, <br /> I <br />