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<br /> DCPZP-217-00664
<br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION
<br /> OWNER NAME,, PHONE AGENT/CONTRACTOR NAME PHONE
<br /> BROOKE S.GROSKOPF (970)`903-7791
<br /> BII LING ADDRESS(Nisaber.$tiaet) �,' , A D o SS s yr b Weill)
<br /> ,
<br /> 270 OL LAND RD r r
<br /> L A F
<br /> State�tppJ
<br /> CAMBRIDGE,WI 53523 , 1 ,
<br /> E-MAILADDRESS 111E ADQAESS
<br /> BSGP OSKO@?GMAILI.COM f ,
<br /> PARCEL NO. TOWNSHIP SECTION ` 1/4 1/41/4
<br /> 0612-•363-8,500 44; '?I , TOWN OF CIi.R(STIANA 36'' SW NW
<br /> FFa 1 .R1 r\L IJRES S1=11q&.^ ',ST DIREQTION STREETNlyttlE ST.TYPE
<br /> ( "" cw a. t �-t r i..r m-.... 1; ti,, o . ... - , ( .[?►�L:•�ND, ...,.•:r.x1 , .. ,
<br /> �.lnv1• 4�n - e � f 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 20 Description:HAY STORAGE BUILDING 20'X 21' 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 gj NO
<br /> SHORELAND FLOOD ZONE WETLAND EC/SW NO.
<br /> ❑ YES ® NO ❑ YES ® NO ❑ YES 0 NO
<br /> HEIGHT(In Feet) BASEMENT 1st FLOOR TOTAL SQUARE FEET
<br /> 13'MEAN Sq.Ft. Sq.Ft.420 420
<br /> PROJECT COST
<br /> NO.OF STORIES 2nd FLOOR 3rd FLOOR $8,900.00
<br /> 0 Sq.Ft. Sq.Ft. PERMIT FEE
<br /> $81.50
<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 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 iiiir .r. ances.
<br /> Owner&Agent hereby agree to comply with all Dane County l.:-;!..:::.! : e°' �'
<br /> Ordinances.Any unauthorized change from the information or riftiliqui /plans submitted will invalidate the permit. .�_�, 0 Li (7
<br /> OFFICE USE ONLY (form version 03.01.01)
<br /> SURVEY REQUIRED? DATE ISSUED INITIALS 1st IN "V TION DATE INITIALS
<br /> 10/03/2017 SLJ3
<br /> ❑ YES ® NO DATE REVIEWED INITIALS 2nd INSPECTION DATE INITIALS
<br /> II
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