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DANE COUNTY ZONING PERMIT DCPZP-2015-00751 Page 1of2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> JOAN H GORMAN (608)225-0548 HOLLER & SONS, INC. (608)444-9589 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 1734 SAWTOOTH LANE P. O. BOX 163 <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53719 BLACK EARTH, WI 53515 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JOANHGORMAN @GMAIL.COM QUAGLIANA @CHARTER.NET <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0806-163-9790-0 TOWN OF MAZOMANIE 16 SW SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 5641 WILLOUGHBY RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 09798 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-3 Rural Homes 10.1 Description:SFR WITH SCREENED PORCH AND DECK 101 - SFR (detached) <br /> District <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> ❑ Other: <br /> Private 13-2015-00264 <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO DEED RESTRICTION <br /> C-Town Road 7733 <br /> ❑ YES ❑ NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> 0 YES ® NO ❑ YES ® NO ❑ YES ® NO EC2015-0317 <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 2910 <br /> 22 Sq.Ft.750 Sq.Ft.2160 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $250,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $268.25 <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 SIGNATURE: O er/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. Ch. - r �:.t.. `t VI k <br /> OFFICE USE ONLY (form version 03.00.07) <br /> - <br /> SURVEY REQUIRED? DATE ISSUED INITIALS Illir 1st INSPECTION DATE INITIALS <br /> 09/21/2015 PMK2 <br /> ❑ YES ® NO DATE RE IEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: GJ� Q�p-'J'I` t Z / �J <br />