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Dane County For Office Use Only-Revised 01.08.2014 <br /> Permit Number: <br /> Shoreland Mitigation Application Received By: Dater <br /> Permit Application Application Approved By: Date: <br /> (Application must be made in person. <br /> Incomplete applications will not be accepted) Associated Permits: <br /> Project Name:Buchner Residence Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Brandon&Tonya Buchner Applicant Name: Peter D . Fortlaqe <br /> Landowner Address: 4138 Veith Ave . Applicant Address: 2801 International Lane <br /> Madison, WI 53704 Suite 101, Madison WI 53704 <br /> Landowner Phone: (608) 512-6052 Applicant Phone: (608) 250-9263 <br /> Landowner E-mail: tbuchner102 0 @gmail . com Applicant E-mail: pfortlage @bse-inc . net <br /> Name and company of engineer/consultant who prepared the plans:,Burs e Surveying & Engineering, Inc <br /> Municipality:Town of Vienna Section: 3 6 Quarter:SW Parcel#: 0 9 0 9-3 6 3 -6 6 04-0 <br /> Latitude/Longitude: 43 . 209700 / -89 .376100 <br /> Lat/long location should be the coordinates at the center of the site as defined in the plan. Decimal <br /> coordinates to 6 places required. (e.g. 43.055978, -89.290669) <br /> Fee Calculation <br /> New Impervious Area........... .......... 3 , 338' ft2x$0.010/ft2 =$ 3 3 . 3 8 <br /> Redeveloped Impervious Area .................................... .... .. .. ...0 ft2x$0.005/ft2 =$ 0 . 0 0 <br /> Restored Vegetative Buffer Area ............................... 0 ft2 $500=$ 0 . 0 0 <br /> Base Fee: $400 OR Base Fee=$ 400 . 00 <br /> El Check box to apply$100 flat fee for projects meeting criteria of s. 11.50(6)(a) <br /> Total Fee=$ 433 . 38 <br /> [Not all fee categories may apply,see s. 11.50,DCCO for applicable fees] <br /> Notes: <br /> 1.All requirements included in this application correspond to the requirements set forth in Chapter 11 of the Dane County Code of <br /> Ordinances. <br /> 2. By submitting this application, the permittee and landowner allow Dane County staff to enter the property for inspection and/or <br /> curative action(s. 11.05(5)(a)3). <br /> 3. Late filing fee: The permit fee shall be doubled where wo has begun before a permit has been obtained (s.11.50(7)). <br /> Applicant Signature: r Date: B/21S <br /> If the person submitting the application is of the la 'owner,a notarized statement authorizing the applicant to act as the <br /> landowner's agent must be attached. <br /> This application must be sjbmitted in person (M-F, 8 A.M. — 4 P.M.) <br /> with two copies of all permit materials & fees to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />