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DANE COUNTY ZONING PERMIT DCPZP-2016-00090 Page 1 of 2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> MADISON ACADEMY INC (608) 850-6000 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 5606 RIVER RD <br /> (City,State,Zip) (City,State,Zip) <br /> WAUNAKEE, WI 53597 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0809-144-9322-6 TOWN OF WESTPORT <br /> 14 SE SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 5606 RIVER 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: New Structure/Addition CENSUS CODE <br /> Development District 16.53 Description:temp.crane 329-Other <br /> Category ❑ Residential ® Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> El Other <br /> Private <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> C-Town Road YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> ❑ YES gj NO ❑ YES ® NO El YES ® NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 0 <br /> 190 Sq.Ft. Sq.Ft.0 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $0.00 <br /> 0 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $200.00 <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 ■ ww.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: OwneriAgent DATE: <br /> Ordinances.Any unauthorized change from the information or /�.-" ? ; r; �/. <br /> plans submitted will invalidate the permit. , I / /7 <br /> OFFICE USE ONLY (form version 03.00.07) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 03/16/2016 SSA1 <br /> ❑ YES ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: �1•7 <br />