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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO Page 1 of 2 <br /> DCPSHL-2016-00096 <br /> OWNER INFORMATION AGENT CONTRACTOR INFORMATION <br /> CANNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> MULTIPLE OWNERS DANE COUNTY DRAINAGE BOARD (608)833-5740 <br /> BIWNG ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 6509 OLYMPIC DR <br /> (City,State.Zip) (City,State,Zip) <br /> MADISON, WI 53705 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> LRMASSIE @WISC.EDU LRMASSIE @WISC.EDU <br /> PARCEL NO TOWNSHIP SECTION 1/4 1/41/4 <br /> 0911-082-8000-5 TOWN OF BRISTOL 8 NW NE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address Is <br /> subject to field verification.) <br /> LOT (BLOCK I C.S.M.NO.or PLAT NAME <br /> METES AND BOUNDS <br /> ZONING DISTRICT PARCEL SO FOOTAGE PROPOSED PROJECT: € �-' <br /> A 1 Ex Exclusive Ag Description:DRAINAGE DISTRICT 21 MAINTENANCE ; <br /> District <br /> PROJECT INFORMATION APP for Other:REMOVAL OF VEGETATION SEWER <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND ` e. <br /> m e <br /> ® YES NO YES ❑ NO ® YES ❑ NO - <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft. Sq.FL <br /> Setback from Ordinary High Water Mark Water Body Name ..t , <br /> PERMIT FEE <br /> -C , $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/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit <br /> DATE ISSUED INITIALS INSPECTION DATE INfT1ALS <br /> 11/23/2016 HJH3 <br /> DATE REVIEWED INITIALS <br />