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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1of2 <br /> DCPSHL-2017-00012 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> JEFFREY J SCHUETZ (608) 212-8067 COMBS &ASSOCIATES (608) 752-0575 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 1022 E LAKESIDE DR 109 W MILWAUKEE ST <br /> (City,State,Zip) (City,State,Zip) <br /> EDGERTON, WI 53534 JANESVILLE, WI 53548 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JESCHUETZ @CLINTONWIS.COM AGRIFFIN @COMBSSURVEY.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0512-144-9400-0 TOWN OF ALBION <br /> 14 SE SW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 800 HILLSIDE RD <br /> subject to field verification.) <br /> LOT BLOCK I C.S.M.NO.or PLAT NAME <br /> 1 CSM 14355 <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition ° .: <br /> A-2 Agriculture 248161 Description:DRIVEWAY AND SFR ° . „4, ' <br /> District } <br /> A for a Residential Structure;App for Other:0 SEWER x 6” <br /> PROJECT INFORMATION PP PP � � �> <br /> Septic <br /> RIVEWAY ,., <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION r---` _ , <br /> 10948 YES ® NO 1 s <br /> SHORELAND FLOOD ZONE WETLAND ` a I <br /> ® YES 0 NO 0 YES ® NO 0 YES ® NO ". t om n 1, A > <br /> a- > <br /> Existing Impervious Proposed Impervious 4-744''''' : "a�' <br /> Sq.Ft.0 Sq.Ft.7290 t - 4 " w <br /> Vi a{ .' <br /> Setback from Ordinary High Water Mark Water Body Name <br /> s"�x„ha .fig:-x ,#.� � „ '"r� W 4W <br /> I, ��"' � � � �� PERMIT FEE <br /> 88 RICE LAKE <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: Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. V -.IL )•------ 3) I <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 03/09/2017 HJH3 <br /> DATE REVIEWED INITIALS <br />