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DANE COUNTY ZONING PERMIT DCPZP-2016-00491 Page l of 2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DREW HJELM (608)469-6863 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 1605 COTTAGE GROVE RD <br /> (City,State,Zip) (City,State,Zip) <br /> DEERFIELD, WI 53531 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> drew.hjelm @gmail.com <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0711-131-9550-2 TOWN OF COTTAGE GROVE 13 NE SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 1605 COTTAGE GROVE RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 06174 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: Alteration to existing building CENSUS CODE <br /> RH-1 Rural Homes 2.10 Description:26'x 16'a 22'gar addn to sfr 438-Garage <br /> District <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> Private <br /> ❑ Other: <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> B-County Highway DCPREZ-2016-1990- <br /> ❑ YES ❑ NO <br /> nA7']Q <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> ❑ YES Ej NO ❑ YES U NO ❑ YES ❑ NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 416 <br /> 22 Sq.Ft. Sq.Ft.416 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $30,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $81.20 <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 certi`fjr that the Wolrk 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 a t(oe.- - <br /> � t-.......��i..n"..a:6..•. ,r✓..s l�a, eNw rk"rte <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 /> , <br /> Owner&Agent hereby agree to comply with all Dane County SIGNATURE' er - tr % DATE: J <br /> plans submitted Any will invalidate the from the information or A <br /> ��`%% ?7 0/ // <br /> plans submitted will invalidate the permit. <br /> . OFFICE USE ONLY (form version 03.01.00) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 08/03/2016 RLB <br /> ❑ YES ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: /6/' <br />