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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- - <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name !! Agent Name r <br /> 3 z pdN L J v i�t.f FCRK13>.C.-K '�ycfaa - j ONiisor <br /> Address Agent Address <br /> a968 4-41,6k s/fi- Avg LI Qail MoZs L <br /> City,State,Zip City,State,Zip <br /> A 0-1>Z3'fl/" r 4/j SS 7// (9# N4frE A/1.-- c"3,5-5--Phone Agent'Phone <br /> ‘e8 �o, —�(---- 6�6 6 <br /> E-Mail Agent E-mail <br /> Sp h!E?011E6'4-0 CC/r, ,e-- .04-7 JoYisar✓ p <br /> f9o�1-Da..,ritrlJ). 6, <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> -c - A-JF 17.,1J rS 'h 'h% . a$ <br /> Parcel Numbe Zoning District <br /> Off;/o oSI'f Q13 7 <br /> CSM Lot Subdivision Block/Lot <br /> 13 kl(N./1'1IC/ - 'gavel{ <br /> Project Description <br /> sip AIL/A <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?tg Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property?1 Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? INNo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes ki o <br /> Have you contacted the Dane County Land and Water Resources Department about this project? Nt 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 /> El <br /> 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 fo - - oreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property o j.- . dul :uthorized representative,and may sign this permit application on the <br /> 4,behalf of the owner(s)of said .:•‘: <br /> Applicant signature: C� Date: 3-,1'1 r <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />