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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPSHL-2017-00039 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DANIELLE ZILM <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 4129 DWIGHT DR <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53704 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0810-104-4101-8 TOWN OF BURKE 10 SE SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is Pon d 1 0) <br /> subject to field verification.) <br /> LOT BLOCK I C.S.M.NO.or PLAT NAME <br /> 1 LOTHE WOODS <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition <br /> R-1 Residence 5995 Description:SFR W/DECK <br /> District . . ���� �' <br /> PROJECT INFORMATION App for a Residential Structure; SEWER <br /> Septic <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> � <br /> 1664 ❑ YES ® NO b �a`� ` <br /> SHORELAND FLOOD ZONE WETLAND :� � <br /> ® YES ❑ NO 0 YES ® NO ❑ YES ® NO � ' � v <br /> .. yo-- 'YM- ." A*��. • ."�^.e,q., ^.�c S'�� ..:> 1 «. <br /> Existing Impervious Proposed Impervious " i ( -, <br /> SG.Ft.0 Sq Ft.665 % i �- - F "`, 7 � i <br /> w Y p Ap :: , ,Hky °a, <br /> Setback from Ordinary High Water Mark Water Body Names :" � -��r a <br /> 280 UNNAMED 1 ak a '° PERMIT FEE <br /> k <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 SIGNATURE: i wner/Ag- t DATE: <br /> Ordinances.Any unauthorized change from the information or 1 <br /> plans submitted will invalidate the permit. 1 CS • 1 <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 06/09/2017 HJH3 <br /> DATE REVIEWED INITIALS <br />