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DANE COUNTY ZONING PERMIT Page oft <br /> DCPZP 2017-00253 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DAVID E JADACK (608) 393-4160 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 10718 AMENDA RD <br /> (City,State,Zip) (City,State,Zip) <br /> MAZOMANIE, WI 53560 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> djadack @gmaii.com <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0806-053-8641-8 TOWN OF MAZOMANIE 5 SW NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 10718 AMENDA RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 06273 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-2 Rural Homes 4.797 Description:50'x60'pole building 329-Other <br /> District <br /> Category ® Residential ❑ Commercial ❑ Agricultural SEWER SANITARY PERMIT NO. <br /> ❑ Other: Private <br /> ROAD CLASSIFICATION REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> C-Town Road 4155 ❑ 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 /> 3000 <br /> 25 Sq.Ft. Sq.Ft.3000 <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $50,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $275.00 <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 SIG T RE: Owner/•4 ent , DATE: <br /> Any unauthorized change from the information or 0 / I d..-d` 5-I G Q !t <br /> '- <br /> plans submitted will invalidate the permit. <br /> OFFICE USE ONLY (form version 03.01.01) <br /> SURVEY REQUIRED? DATE ISSUED 'INITIALS 1st INSPECTION DATE INITIALS <br /> 05/10/2017 SSA1 <br /> ❑ YES ® NO DATE REVIEWE D INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: �� / <br /> Si l III PI - <br />