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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1of2 <br /> DCPSHL-2017-00026 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> BRIAN D DRAGER (608) 220-6895 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 10718 W HUDSON RD <br /> (City,State,Zip) (City,State,Zip) <br /> MAZOMANIE, WI 53560 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> BRIANDRAGER @HOTMAIL.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0806-083-9710-0 TOWN OF MAZOMANIE 8 SW SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 10718 W HUDSON RD <br /> subject to field verification.) <br /> LOT BLOCK I C.S.M.NO.or PLAT NAME <br /> 1 CSM 10581 <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition <br /> RH-4 Rural Homes 597822 Description:REPLACEMENT OF CHICKEN COOP/GARAGE *;,,q, : <br /> District <br /> z,ti <br /> PROJECT INFORMATION App for a Residential Structure; SEWER <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> 8475 ; , <br /> , 01'❑ YES NO <br /> SHORELAND FLOOD ZONE WETLAND " - r `fi x <br /> YES ❑ NO ❑ YES ® NO ❑ YES ® NO <br /> � . <br /> Existing Impervious Proposed Impervious <br /> :i .. <br /> Sq.Ft.9000 Sq.Ft. 10600 � :y <br /> Setback from Ordinary High Water Mark Water Body Name _; <br /> PERMIT FEE <br /> 180 BLACK EARTH CREEK $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 S AT :E: Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or tat.,submitted will invalidate the permit. , , tl •• Q—r <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 04/20/2017 HJ H 3 <br /> DATE REVIEWED INITIALS <br />