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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1of2 <br /> DCPSHL-2017-00069 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> DAVID A CASIMIR (608) 662-1277 MEIGS, INC <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> PO BOX 930498 PO BOX 412 <br /> (City,State,Zip) (City,State,Zip) <br /> VERONA, WI 53593 BLACK EARTH, WI 53515 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> DACASIMIR @CASIMIRJONES.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0707-171-9561-0 TOWN OF CROSS PLAINS 17 NE SE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 4197 BARLOW RD <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> 1 CSM 07349 <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition <br /> RH-4 Rural Homes 798462 Description:RESIDENTIAL STORAGE BUILDING <br /> District <br /> PROJECT INFORMATION App fora Residential Structure; SEWER 3_` <br /> Septic <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> 5757 ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND r ` <br /> ® YES 0 NO 0 YES ® NO 0 YES ® NO ` MP <br /> Existing Impervious Proposed Impervious t c <br /> Sq.Ft.15067 Sq.Ft. 18267 <br /> Ver <br /> Setback from Ordinary High Water Mark Water Body Name <br /> 75 UNNAMED PERMIT FEE <br /> fy $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 • Dane County zoning inspectors for the <br /> purposes of determining compliance with the zoning ore :nc s. <br /> Owner 8 Agent hereby agree to comply with all Dane County SIGN, ' Own r/ ( DATE/ <br /> Ordinances.Any unauthorized change from the information or � <br /> plans submitted will invalidate the permit. 2 i' 0)7 <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 09/11/2017 HJH3 <br /> DATE REVIEWED INITIALS <br />