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DANE COUNTY SHORELAND ZONING PERMIT DZONING CPSHL-2016-00025 <br /> -2016 0 Page1of2 <br /> DCPSHL-2016-00025 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> THOMPSON REV LIVING TR,CRAIG B&MARGARET S (608) 873-9684 MOYER'S INC (608)235-6741 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 3012 SHADYSIDE DR 936 STARR SCHOOL RD <br /> (City,State,Zip) (City,State,Zip) <br /> STOUGHTON, WI 53589 STOUGHTON, WI 53589 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> MATT.HANNA @MOYERSI NC.N ET <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0611-304-4201-7 TOWN OF PLEASANT SPRINGS 30 SE SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 3012 SHADYSI DE DR <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 ATKINSON'S ADDITION, CRYSTAL SPRINGS PARK <br /> ZONING DISTRICT PARCEL SQ FOOTAGE a <br /> PROPOSED PROJECT: ""� ��� <br /> R-3 Residence 10849 Description:REPLACEMENT OF EXISTING IMPERVIOUS <br /> District SURFACES <br /> PROJECT INFORMATION App for Landscaping; SEWER o. a <br /> Sewer <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> r <br /> ❑ YES ® NO <br /> , t <br /> .i n § - <br /> SHORELAND FLOOD ZONE WETLAND <br /> ® YES 0 NO p YES 0 NO 0 YES ® NO <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft.420 Sq.Ft.420 <br /> Setback from Ordinary High Water Mark Water Body Name ,, „ <br /> 8 "' PERMIT FEE <br /> LAKE KEGONSA <br /> s :. <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 <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 SIGNAT - ,i ne /Agent DATE: <br /> Ordinances.Any unauthorized change from the information or 11 1/ <br /> plans submitted will invalidate the permit. / / !b <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 05/11/2016 HJH3 <br /> DATE REVIEWED INITIALS <br />