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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page lof2 <br /> DCPSHL-2016-00045 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DANE COUNTY DANE COUNTY PARKS <br /> BILLING ADDRESS(Number.Street) ADDRESS(Number,Street) <br /> 210 MARTIN LUTHER KING BLVD RM 114 5201 FEN OAK DR <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53703-3342 MA, WI 53718 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0508-142-8510-0 TOWN OF MONTROSE 14 NW NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 1065 STATE HIGHWAY 69 <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> METES AND BOUNDS <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: <br /> A-1 Ex Exclusive Ag Description:SUGAR RIVER HABITAT IMPROVEMENT AND <br /> District FORD <br /> PROJECT INFORMATION App for Landscaping;App for Other. SEWER <br /> Septic <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND <br /> YES ❑ NO ® YES El NO ® YES ❑ NO <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft Sq.Ft. <br /> Setback from Ordinary High Water Mark Water Body Name <br /> PERMIT FEE <br /> $0.00 <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 SIGNATURE: Owner/A•ent DATE: <br /> Ordinances.Any unauthorized change from the information or PO' r <br /> plans submitted will invalidate the permit. " j <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 07/06/2016 HJH3 <br /> DATE REVIEWED INITIALS <br />