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Dane County Shoreland Zoning zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- 41h Sato <br /> ihr Application must be made in person Zoning Permit#DCPZP- - CM <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 ......-- Name <br /> As ei.)df-cS <br /> Address Agent Address <br /> 9 (8 /OigT , uecJ.t_L <br /> City�,,State,Zip City,State,Zip <br /> /'1172 /Ua Wit-2— <br /> Phone LA) 0 r/� Agent Phone <br /> ADS- � CoOK £0 <br /> E-Mail Agent E-mail <br /> re_irJits cd- c.utmc , , co0 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 90��a Alee luk e,k,L A'A yo <br /> Parcel Number(s) Zoning District <br /> ,v A C6Vog01)-30111-3g°04 <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> Q ut i L el Po L-2 kA 1 U di - -r-a ' -Pi 4 r rn C u i ,me„,./7- <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 from a pond or lake? Yes ❑No ❑ Don't Know <br /> rs <br /> Is there a wetland or floodplain on or near the property? ❑Yess / o , D on't Know <br /> Is this project associated with a recent rezone/CUP/variance? Leo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes 10 / <br /> Have you contacted the Dane County Land((and Water Conservation Department about this project? Yes ❑No <br /> Most applications must be accomnanied, inq 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 /> ❑ All impervious surfaces at time of application submittal. Checks are <br /> ❑ All vegetative areas payable to Dane County Zoning. The fee for <br /> ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> ❑ Topographic data(2-foot contours) non-refundable. <br /> I,the undersigned, hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property owner,or a duly authorized representative,and may sign this permit application on the <br /> behalf of the owner(s)of sai operty. <br /> Applicant signature: �'� 1.,- 6 Date: 1 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />