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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- 1 S <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name t <br /> G C4li=rt7 .�Poi-) t ..�c k c /:7 €: �.y Y;r.«- <br /> Address Agent Address <br /> `I'7a i"1?o))-1 to sE PO <br /> City,State,Zip City,State,Zip <br /> Phone Agent Phone <br /> 60S — �~- — ' U$ s-? .T 3 ' <br /> E-Mail Agent E-mail <br /> k7 -1-21e C . C � !�1�Zjc.r+rY# t rvZS,r7O.C€i <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> ai7O 4/4vi>g3 - Pr.� /, Y,� . 27 <br /> Parcel Number(s) Zoning District <br /> GSM Lot Subdivision glock/Lot <br /> f �3 s`✓} <br /> 47,,,s2€4/ <br /> Project Description <br /> TF1) . i , 2Tl3 —c <br /> Please answer the following questions to the best of your ability: <br /> Is the property within 300 feet of a stream or 1 000 feet from a pond or lake? l Yes DNo D Don't Know <br /> Is there a wetland or floodplain on or near the property? 1W Yes DNo ❑Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? CI No If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes IBI.No <br /> Have you contacted the Dane County Land and Water Resources Department about this project?l<Yes DNo <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 contours) non-refundable. <br /> I,the undersigned,hereby make .:. icatio�. oreland zoning permit and certify to the accuracy of the information. <br /> further certify I am the prope • -r, • •ul authorized representative,and may sign this permit application on the <br /> behalf of the owner(s)of s-'• p •e <br /> Applicant signature: Date. Jl <br /> H:':Zoning\Shoreland-Wetland Zoning;Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />