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DANE COUNTY ZONING PERMIT DCPZP-2015-00906 Pagel oft <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> STEPHEN P BLOCK I (i Oa 7,.7Cn6 Cleary Building Corp. <br /> BILLING ADDRESS(Number,Street) Y ADDRESS(Number,Street) <br /> 6452 SHADY BEND RD <br /> (City,State,Zip) (City,State,Zip) <br /> VERONA, WI 53593 <br /> E-MAIL' D RE E-MAIL ADDRESS <br /> I b a; 1 . C0rn <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0608-251-8580-0 TOWN OF VERONA 25 NE NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 6452 SHADY BEND RD <br /> subject to field verification.) <br /> LOT BLOCK I C.S.M.NO.or PLAT NAME <br /> 1 CSM 12254 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-1 Rural Homes / Description: ( 0/ X t/s / - : ji S�i O 434- Residential Addition <br /> District OZ. 7 ,•��� <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER i Civa ti a SANITARY PERMIT NO. <br /> o Other: Piwate <br /> ROAD CLASSIFICATION REZONE nn. <br /> NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> C-Town Road y? c.( 0 YES ® NO <br /> SHORELAND FLOOD ZONE V WETLAND EC/SW NO. <br /> ❑ YES ® NO ❑ YES ® NO ❑ YES la NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 1920 <br /> 22 Sq.Ft. Sq.Ft.1920 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $27,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $194.00 <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 ordinance <br /> Owner&Agent hereby agree to comply with all Dane County SIGNATURE: • r/A / t / DA : <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit / -- <br /> OFFICE USE ONLY (form version 03.00.07) <br /> SUR ' -EQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> I, 11/09/2015 RWL1 <br /> ❑ YES ® NO DATE REVIEWED INITIALng 2nd INSPECTION DATE INITIALS <br /> Initials: L� I/^ ? 1..] \7 rig <br />