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DANE COUNTY ZONING PERMIT DCPZP 20 7 00512 Pagelof2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> JOHN W BEASLEY QUALITY WEST CONSTRUCTION INC (608) 798-3774 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 489 SUGAR HILL RD P.O. BOX 12 <br /> (City,State,Zip) (City,State,Zip) <br /> BROOKLYN, WI 53521-9445 MOUNT HOREB, WI 53572 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JBEASLEY @FAMMED.EDU QUALITYWESTINC @GMAIL.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0509-281-6280-0 TOWN OF OREGON <br /> 28 NE SE <br /> PROPERTY ADDRESS HOUSE NO ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 489 SUGAR HILL RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M. NO.or PLAT NAME <br /> 3 CSM 13053 <br /> ZONING DISTRICT PARCEL ACREAGE PROPOSED PROJECT: New Structure/Addition CENSUS CODE <br /> RH-3 Rural Homes 9 Description.HOME ADDITIONS-GARAGE, DECK AND PORCH 434 - Residential Addition <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 /> C-Town Road 10253 <br /> E YES NO <br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO. <br /> ❑ YES ® NO ❑ YES 0 NO ❑ YES 0 NO <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET <br /> 740 <br /> 15 Sq.Ft Sq.Ft.740 <br /> PROJECT COST <br /> NO OF STORIES 2nd FLOOR 3rd FLOOR $110,000.00 <br /> 1 Sq Ft Sq Ft PERMIT FEE <br /> $105.50 <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: Owne- .r m"- DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> inif _ ------- <br /> plans submitted will invalidate the permit. f Yj =-///7 <br /> OFFICE USE ONO( (form version 03.01.01) <br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st INSPECTION DATE INITIALS <br /> 08/11/2017 PMK2 <br /> ❑ YES ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> �; <br /> Initials l`7.4.1 l� <br />