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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of2 <br /> DCPSH L-2020-00111 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> !MICHAEL N AYERS (608)215-8949 CARRICO ENGINEERING (608)213-9718 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 8692 AIRPORT RD 1926 N KOLLATH RD <br /> (City,State,Zip) (City,State,Zip) <br /> MIDDLETON, WI 53562 VERONA, WI 53593 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> AYERS829@GMAIL.COM ADAM@CARRICOENGINEERING.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0808-301-8690-0 TOWN OF SPRINGFIELD 30 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 /> 1 CSM 15278 <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition <br /> 43918 Description:SINGLE FAMILY RESIDENCE <br /> PROJECT INFORMATION App for a Residential Structure; SEWER <br /> Septic <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> ❑ YES IA NO <br /> SHORELAND FLOOD ZONE WETLAND <br /> YES 0 NO p YES ® NO El YES ® NO <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft.0 Sq.Ft.4860 <br /> Setback from Ordinary High Water Mark Water Body Name <br /> 85 UNNAMED PERMIT 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 SIGNATURE: Owner/Agent DATE: <br /> Ordinances.Any unauthorized change from the information or Dig•tally signed by AVERS.MICHAEL.N.1136537446 <br /> plans submitted will invalidate the permit. AYERS.MICHAEL.N.1136537446 Date:2o2t.o5.26bL,3z32+03•o0 25 May 2021 <br /> OFFICE USE ONLY (form version 02.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 05/25/2021 H J H 3 <br /> DATE REVIEWED INITIALS <br />