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DANE COUNTY SHORELAND ZONING PERMIT CZONING PSHL-201T00. Page1of2 <br /> DCPSHL-2017-00057 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DANE COUNTY (608) 224-3730 DANE COUNTY PARKS (608) 224-3743 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 210 MARTIN LUTHER KING JR BLVD RM 114 5201 FEN OAK DR RM 208 <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON,WI 53703 MADISON, WI 53718 - <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> CLOSE.SARAH @COUNTYOFDANE.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0607-331-8593-0 TOWN OF SPRINGDALE 33 NE NW <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> METES AND BOUNDS <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition <br /> A-1 Agriculture Description:DONALD PARK BRIDGE <br /> District REPLACEMENT OVER MOUNT VERNON CREEK g a a ? <br /> PROJECT INFORMATION App for Other.BRIDGE SEWER , <br /> Septic yw R <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION - 3 t <br /> YES Ea NO <br /> SHORELAND FLOOD ZONE WETLAND r <br /> YES U NO ® YES El NO 0 YES ❑ NO <br /> • <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft. Sq.Ft. <br /> Setback from Ordinary High Water Mark Water Body Name <br /> MOUNT VERNON CREEK IPERMIT FEE <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 subject <br /> 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 difficult <br /> to identify. Failure to comply may result in removal or modification of construction that violates the law or <br /> other penalties or costs. For more information, visit the Department of Natural Resources web page at <br /> 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 SIIl A. J a 61�i E7A'f <br /> Ordinances.Any unauthorized change from the information or ". ... "` <br /> plans submitted will invalidate the permit. b 11-1 t✓ <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED !ILS INSPECTION DATE INITIALS <br /> 08/11/2017 HJH3 <br /> DATE REVIEWED INITIALS <br />