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DANE COUNTY ZONING PERMIT DCPZP 20 6-00425 Page 1of2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> GRUNDAHL REV TR,JEFFREY A&MARY L (608) 576-7850 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 10964 COUNTY HIGHWAY A <br /> (City,State,Zip) (City,State,Zip) <br /> HOLLANDALE, WI 53544 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0606-271-8600-0 TOWN OF BLUE MOUNDS 27 NE NW <br /> PROPERTY ADDRESS HOUSE NO ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 10101 BARTON RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 12585 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> A-2 (4)Agriculture 6 Description:80'X 42'ACCESSORY BUILDING 329 - Other <br /> District <br /> Category J Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> 0 Other: <br /> Private 13-2015-00294 <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO VARIANCE NO DEED RESTRICTION <br /> C-Town Road 9899 YES ® NO <br /> SHORELAND e ticr, FLOOD ZONE WETLAND EC/SW NO. <br /> 0. YES st NO ❑ YES © NO ❑ YES ( NO EC2015-0344 <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 4160 <br /> 26 Sq.Ft. Sq.Ft.3360 <br /> PROJECT COST <br /> NO OF STORIES 2nd FLOOR 3rd FLOOR $100,000.00 <br /> 2 Sq.Ft.800 Sq.Ft. PERMIT FEE <br /> $362.00 <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 ordinances. <br /> Owner&Agent hereby agree to comply with all Dane County SIGNATURE ?owner//gent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. '` 7 <br /> OFFICE USE ONLY (form version 03.01.00) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 07/11/2016 PMK2 <br /> ❑ YES © NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: <br />