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DANE COUNTY SHORELAND ZONING PERMIT CPSH 221500 Pagelof2 <br /> DCPSHL-2015-00014 <br /> OWNER INFORMATION AGENT/CONTR,ACTIMJIMQ 4;ti, ,*,-.4. <br /> OWNER NAME PHONE AGEN I/CONTRAC1 OR NAVE I I';tii= <br /> JOHN A PLAMBECK (608) 233-0782 THE HOUSE DOCTORS M D.; INC. (608) 745-88E 0 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 2968 WAUBESA AVE W8024 MORSE RD <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53711 POYNETTE, WI 53955 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JPWAUBESA @CHARTER.NET TJOHNSON @HOUSEDOCTORSMD.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0610-054-2333-7 TOWN OF DUNN 5 SE NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 2968 WAUBESA AVE <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 13 2 WAUBESA BEACH- <br /> ZONING <br /> DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: Alteration to existing building <br /> R-3 Residence 11998 Description:SFR ADDN AND REMOVAL OF EXISTING <br /> District IMPERVIOUS SURFACE <br /> PROJECT INFORMATION App for a Residential Structure; SEWER <br /> Sewer <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> O YES 0 NO <br /> SHORELAND FLOOD ZONE WETLAND <br /> ® YES t] NO 0 YES ® NO O YES ® NO <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft.5211 Sq.Ft.5194 <br /> Setback from Ordinary High Water Mark Water Body Name <br /> 160 LAKE WAUBESA PERMIT FEE <br /> $150.00 <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 cc:nst-uction <br /> near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be c' if c alt <br /> to identify. Failure to comply may result in removal or modification of construction that violates the law cr <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 SIGNAT I'M': O - • . t ATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. ., ., / ,/!J. <br /> i <br /> OFFICE USE%;N! f " , ,:. <br /> DATE ISSUED INI•i�S TS LCIIO‘HAIE I'T <br /> 03/24/2015 I IJI 13 <br /> DATE REVIEWED ITIALS <br /> I <br />