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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 <br /> DCPSHL-2017-00049 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> LAZZARO REV TR, JACK H (847) 304-9671 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 1994 SELKIRK CT <br /> (City,State,Zip) (City,State,Zip) <br /> INVERNESS, IL 60010 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JACK_LAZZARO@ AJG.CO <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0610-253-3120-1 TOWN OF DUNN 25 SW NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 3392 QUAM DR <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 10 QUAM'S PARK, OLE J,ADDITION TO <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: Alteration to existing building <br /> , ,s R-3 Residence 17578 Description:SFR REMODEL AND ADDITION K <br /> District v 7i <br /> PROJECT INFORMATION App fora Residential Structure; SEWER OC '4, <br /> Sewer <br /> y � <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION 1 <br /> 813 ❑ YES ® NO F, <br /> SHORELAND FLOOD ZONE WETLAND ✓ r <br /> ® YES 0 NO 0 YES ® NO 0 YES ® NO S <br /> a <br /> Eastin Impervious Proposed Im pervious <br /> Sq.Ft.4552 Sq.Ft.5804 <br /> Setback from Ordinary High Water Mark Water Body Name ,r s K� <br /> 63 LAKE KEGONSA , ito PERMIT FEE <br /> X14 1- * -k£. $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 G'iii&URE: Own- /A• -nt •TE: <br /> Ordinances.Any unauthorized change from the information or <br /> plans submitted will invalidate the permit. . AMP 7 J <br /> • � —` _ <br /> OFF.%.;E USE ONLY (form version 01.C1.00) <br /> DATE ISSUED INITIALS ,iiiiVN DATE INITIALS <br /> 07/11/2017 HJH3 <br /> DATE REVIEWED INITIALS <br />