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DANE COUNTY ZONING PERMIT DCPZP 2016-00377 Page of <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE -N 71/ROLAND G SCOTT Todd Seiler 608-228—� <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 2359 COUNTY HIGHWAY E 2932 Green Avenue <br /> (City,State,Zip) (City,State,Zip) j <br /> MT HOREB, WI 53572 Blue Mounds, WI 53 5 / <br /> E-MAIL ADDRESS E-MAIL ADDRESS JJ <br /> roland.scott@gmail.com +0 A(E ?se.; Ie 1st.1'Oa i I,CO IY\ <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0606-222-9160-7 TOWN OF BLUE MOUNDS <br /> 22 NW SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 2359 COUNTY HIGHWAY E <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 04514 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: Alteration to existing building CENSUS CODE <br /> A-1 Ex Exclusive Ag 9 Description:Mst Bdrm,fam rm,2 bath,hobby room addn to sfr 434- Residential Addition <br /> District <br /> Category IO Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> ❑ Other: Private E N A h <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> B-County Highway <br /> ❑ YES ❑ NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> 0 YES El NO ® YES ❑ NO 10 YES ❑ NO SE-2016-0194 <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 24 Sq.Ft.528 Sq.Ft.560 1088 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $80,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $131.60 <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 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. Wetlands that are not associated with open water can be difficult <br /> to identify. Failure to comply may result in removal 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 /> 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,TUR a• 'r er/Age " DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. '�•_i - - / <br /> OFFICE USE ONLY (form version 03.01.00) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 06/23/2016 RLB <br /> ❑ YES ® NO DATE REVIEWED <br /> /� INITIALS 2nd INSPECTION DATE INITIALS <br /> Initial: fit//_� CY f ^ /Co V��it< <br />