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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPSHL-2017-00044 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> SUSAN WORTH (608) 628-2866 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 2912 WAUBESA AVE <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53711 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> SWORTH1313 @GMAILCOM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0610-053-7231-1 TOWN OF DUNN 5 SW SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 2912 WAUBESA AVE <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 21 3 I WAUBESA BEACH-2ND ADDITION <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition . , . . = <br /> R-3 Residence 8189 Description:12'X 10'DECK ,,Li_ <br /> District <br /> PROJECT INFORMATION App for a Residential Structure;App for Relocati SEWER l� �. <br /> ng Impervious Surfaces; Sewer ti ) <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION+ <br /> ❑ YES ❑ NO r, <br /> SHORELAND FLOOD ZONE WETLAND � -a-t,, ;�n .r� <br /> . <br /> k�0� ,,,-.. ~ <br /> i s a m_l <br /> ® YES ❑ NO ® YES NO ® YES ID NO - <br /> Existing Impervious Proposed Impervious t t ?,C'''''' °.1r T <br /> g <br /> Sq.Ft. 125 Sq.Ft.108 ;z � :a <br /> Setback from Ordinary High Water Mark Water Body Name j "' , � ,, ) <br /> 95 FEET LAKE WAUBESA :: 3,' - PERMIT FEE <br /> l � " $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 SIGNATUR•. Owner/A DATE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. ./ / 1� t(021 / <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 06/21/2017 PMK2 <br /> DATE REVIEWED INITIALS <br />