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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPSHL-2015-00044 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> BLAKE 0 NELSON (608) 334-6200 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 3129 EGRE RD <br /> (City.State,Zip) (City,State,Zip) <br /> SUN PRAIRIE,WI 53590 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> angie.sold©gmail.com - <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0911-312-8610-8 TOWN OF BRISTOL 31 NW NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address Is 3129 EGRE RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 01460 <br /> ZONING DISTRICT PARCEL SO FOOTAGE PROPOSED PROJECT: Alteration to existing building g' r <br /> A-1 Agriculture 41370 Description:22'x 18'tam rm,24'x 14'att gar addn to sfr <br /> District a.' <br /> PROJECT INFORMATION App for a Residential Structure;App for Relocati I SEWER <br /> Private �� <br /> ng Impervious Surfaces; mi ,° <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> D YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND c <br /> ® YES 0 NO 0 YES ® NO ❑ YES ® NO <br /> Existing Impervious Proposed Impervious ... :' <br /> Sq.Ft.4439 Sq.FL 4571 <br /> Setback from Ordinary High Water Mark Water Body Name <br /> 150 UNNAMED 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 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 zoning ordinances. <br /> Owner&Agent hereby agree to comply with all Dane County le,g� rte, , " s ; <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. 40 L f(S" <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 06/09/2015 HJH3 <br /> DATE REVIEWED INITIALS <br />