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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO Page 1 of 2 <br /> DCPSHL-2021-00050 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> JAMES A NEWTON (608) 516-6068 AMBIANCE HOMES, INC (608)225-4594 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 1201 DYNES WAY 5833 GRASSLAND TERRACE <br /> (City,Stale,Zip) (City,State,Zip) <br /> SUN PRAIRIE, WI 53590 MARSHALL, WI 53559 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JAMNEWTO@CISCO.COM AMBIANCEHOMESINC@CHARTER.NET <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0911-121-4075-0 TOWN OF BRISTOL 12 NE SW <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 /> 25 DRUMLIN CREEK <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition • <br /> 16760 Description:SFR <br /> PROJECT INFORMATION App for a Residential Structure; SEWER <br /> Septic <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> YES 0 NO <br /> SHORELAND FLOOD ZONE WETLAND <br /> YES 0 NO it YES ® NO J YES ® NO <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft.0 Sq.Ft. 1243 <br /> Setback from Ordinary High Water Mark Water Body Name <br /> 280 UNNAMEDesti Z rs R PERMITFEE <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 - k I - • Ow A•ggent DATE: <br /> Ordinances.Any unauthorized change from the information or "INIIk <br /> plans submitted will Invalidate the permit. • ` <br /> OFFICE iicE OALY (form version 02.01 00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 06/07/2021 HJH3 <br /> DATE REVIEWED INITIALS <br />