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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shore land Permit#:DCPSHL- - <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name <br /> ADf,1 \ 1 L <br /> AAAddA roTess Agent Address <br /> Cityto e,Zip c , e City,State,Zip <br /> Phone `\ J v, <br /> Agent Phone <br /> EtsGo -•6 33 _ <br /> Agent E-mail <br /> (CNN 0 ,A, - 0 0,\,\,:z1 Ct-,S <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> P ,A.'. =s.� Town/Section Acreage <br /> Parce umber(s) Zoning District <br /> oa \ I I a49—Gs <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> add 1 .S Ca�vr\ -.Xr fi.V\ p b ' ■ar.n> r 201 r <br /> Please answer the following questions to the best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet fro . . pond 'r lake? Yes ❑No ❑Don't Know <br /> Is there a wetland or floodplain on or near the property? I✓ Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/ /variance? '//o If yes, petition/appeal# . <br /> Is this permit to correct a violation? CI Yes MNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑Yes o <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> ❑ All existing structures Permit Fee due at time of application <br /> ❑ Any proposed structures Please have cash or check payment available <br /> o All impervious surfaces at time of application submittal. Checks are <br /> ❑ All vegetative areas payable to Dane County Zoning. The fee for <br /> la <br /> High Water Mark a shoreland zoning permit is$150.00 and is <br /> ❑ Topographic data(2-foot contours) non-refundable. <br /> ur <br /> I,the undersigned,hereby :. - ••plication fora s • eland z• ing permit and certify to the accuracy of the information. I <br /> further certify 1 am the • ;rty own- or a ,11• • • •• - -ntative,and may sign this permit application on the <br /> behalf of the owner(s)of -id property 1 <br /> Applicant signature: \_ ,.it ,1/� Date: <br />