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Dane County Shoreland Zoning Zoning office l' <br /> Permit Application Shoreland Permit#:DCPSHL- 15 - / <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 /> Address Agent Address <br /> 2°) t(a b:) L r).sA Ac\i' . <br /> City,State,Zip City,State,Zip <br /> M <br /> Phone ,�� vV (,f i i 3•"7t <br /> Agent Phone - <br /> q - ql/ 9 <br /> E-Mai C Agent E-mail <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property�Address^'1J^��,C�f�((� Town/Sec/t�iyo�n ��/J Acreage?—114 Parcel Number(s) Zoning District <br /> C)(4O "' 053 7ZZD 4 ._ 3 <br /> CSM Lot Subdivision Block/Lot <br /> ID LID kh.Ct.gGsik 13614-1 Z".A 3 L'T 2-o <br /> Project Description <br /> e4 : f>o ■• =r p t—�■ J T' ' V ` 0.0 - by "ni: 1 fa t-.t D.,iS <br /> .o Fact ,,,,GD lave S R. . zE A-S TaA— 4-,.7 c .,w� <br /> 1 ■Q-,t- • 4 i.> -, v 'l' --1•-,b>._ gxtS( lac1 Pace <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? Zes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ❑No ZDon't Know <br /> Is this project associated with a recent rezone/CUP/variance? ❑No If yes, petition/appeal# . <br /> Is this permit to correct a violation? El Yes [ Io <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes ❑No <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 /> ❑ 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 conto ) non-refundable. <br /> I,the undersigned,hereby ke application for a s reland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the pro rty owner,or a duly rized representative,and may sign this permit application on the <br /> behalf of the owner(s)of sad property <br /> ■ <br /> J <br /> Applicant signature: ` � Date: / 5� <br /> H:\Zoning\Shoreland-Wetland Zoning\CLpter 11 Fotms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />