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DANE COUNTY ZONING PERMIT DCPZP 2016-00701 Page oft <br /> OWNER INFORMATION j AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DANE COUNTY (608)224-3763 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 5201 FEN OAK DRIVE, ROOM 208 <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53718 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JAMES @COUNTYOFDANE.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0807-111-8000-0 TOWN OF BERRY <br /> 11 NE NE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 8183 STATE HIGHWAY 19 <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 /> A-1 Ex Exclusive Ag 40 Description:INDIAN LAKE RESTROOM FACILITY 329-Other <br /> District <br /> Category ❑ Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> Other.MUNICIPAL BUILDING Private 13-2016-00238 <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> A-US or State Highway <br /> YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> YES ❑ NO ® YES ❑ NO ® YES ❑ NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 1320 <br /> 22 Sq.Ft. Sq.Ft.1320 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $240,000.00 <br /> 1 Sq.Ft. Sq.FL PERMIT FEE <br /> $0.00 <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 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 URE: • • - /Agent DATE: <br /> Ordinances.Any unauthorized change from the Information or ,j <br /> plans submitted will invalidate the permit. 0 4, <br /> OFFICE USE ONLY (form version 03.01.00) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 10/24/2016 PMK2 <br /> ❑ YES ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: \1 4C /IV�1�,�-'\ <br />