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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPSHL-2017-00021 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> JENSEN REV TR,ROBERT&DIANNE (608) 235-5456 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 1960 QUAM POINT RD <br /> (City,State,Zip) (City,State,Zip) <br /> STOUGHTON, WI 53589 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JENSENBOBJENSEN @AOL.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0610-253-3034-6 TOWN OF DUNN 25 SW NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 1962 QUAM POINT RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 4 I QUAM'S PARK, OLE J,ADDITION TO <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: "` <br /> R-3 Residence 14663 Description:PARKING AREA AND WALKWAY t ) <br /> i-'1 7 <br /> District " £ . <br /> PROJECT INFORMATION App for Walkway/Stairs;App for Other:PARKING SEWER <br /> "at.- <br /> Sewer <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION < ` . <br /> ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND - , , <br /> ® YES ❑ NO YES ® NO YES ® NO . Attp= , M <br /> Existing Impervious Proposed Impervious r.• � <br /> Sq.Ft.835 Sq.Ft 1250 '" K. <br /> Setback from Ordinary High Water Mark Water Body Name : , 1 �z ,c- <br /> tg , - .. <br /> LAKE KEGONSA ems' LL PERMIT FEE <br /> Y $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 SIGNATU• • Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or � l /7/7 <br /> plans submitted will invalidate the permit. /-----; `�, / �P <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS ' INSPECTION DATE INITIALS <br /> 04/06/2017 HJ H 3 <br /> DATE REVIEWED INITIALS <br />