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DANE COUNTY ZONING PERMIT DCPZP 2017 00563 Page1of2 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE ;AGENT/CONTRACTOR NAME PHONE <br /> MICHAEL S DILLIS (608) 437-0820 MELISSA DESTREE (608) 268-1499 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 3205 BERGUM RD 222 W WASHINGTON AVE SUITE 310 <br /> (City,State,Zip) (City,State,Zip) <br /> MT HOREB, WI 53572 MADISON, WI 53703 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> melissa @destreearchitects.com <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 114 <br /> 0606-031-8000-3 TOWN OF BLUE MOUNDS 3 NE NE <br /> PROPERTY ADDRESS HOUSE NO ST. DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 3205 BERGUM RD <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 41.40 Description accessory structure for storage/greenhouse 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 <br /> ❑ YES ® NO <br /> SHORELAND FLOOI ONE WETLAND EC/SW NO. _SP 41T\Ti <br /> s YES (g NO YES 1�,,-NO ❑ YES ® NO - 0a'�'-0312 <br /> V <br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE <br /> E FEET.-12.00- %y0i <br /> 21'-2" Sq.Ft. Sq.Ft.X00— <br /> PROJECT COST <br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $40,000.00 <br /> 1 Sq.Ft. Sq.Ft. PERMIT FEE <br /> $147.50 <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 SIGN• U ' s. • • r! DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. ._ -w dVG /IP' <br /> OFFICE USE ONLY (form version 03.01.01) <br /> SURVEY REQUIRED? DATE ISSUED INIT' 1st INSPECTION DATE INITIALS <br /> 08/29/2017 SSA1 <br /> ❑ YES ® NO DATE kEVIEWED INITIALS 2nd INSPECTION DATE INITIALS <br /> Initials: 5 <br />