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Dane County Shoreland Zoning Zoning office use only Permit Application Shoreland Permit#:DCPSHL- - Application must be made in person Zoning Permit it DCPZP- Shoreland Zoning Permit fee is$150 A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County Zoning Division for any development within the shoreland district. Property Owner Information Agent Information Name Agent Name ,,\OA 0)2V1 eN t\4\\i\\ V-• 30\/%50A EA-VA Sc�tit Ckl (Cu�.16\mot ��ur:e�(Y-a. � ) Address Agent t Address nt6 \KS\\orl L cq Rd. City,State,Zip City,State,Zip IA e C\ 1 \A\ ?�1;) J e' \ "2111\ Agent Phone 8t`O Cat-2142A E-Mail Agent E-mail e3 Ytkne,2U20 @ '{a\100,CCwA f rO`A C Cow\ Property/Location Information (http://accessdane.co.dane.wi.us) Property Address Town/Section Acreage it vJt\\6\� iouh� ''` ''''`N 2vc, Parcel Number(s) Zoning District Ora I0 it -0412=1 tC;�'� -3 - ocCio t t:3 CSM Lot Subdivision Block/Lot CrMe'* R"\e\C t3 Project Description Remov\ eXc� e'ncre *\\A-\, S • try\live new t:›av or \N;AV\y . ?e-c1c 0-61 in \/\ 5:+n Yn beck- Please answer the following questions to the best of your ability: Is the property within 300 feet of a stream or 1000 feet from a pond or lake? IA Yes ❑No ❑ Don't Know Is there a wetland or floodplain on or near the property? ❑ Yes ❑No 17;1 Don't Know Is this project associated with a recent rezone/CUP/variance?'No If yes, petition/appeal# Is this permit to correct a violation? ❑ Yes 1 .No Have you contacted the Dane County Land and Water Resources Department about this project?'4 Yes ❑No Most applications must be accompanied by a survey showing the following: ❑ Property lines with dimensions ❑ All existing structures Permit Fee due at time of application u Any proposed structures Please have cash or check payment available ❑ All impervious surfaces at time of application submittal. Checks are ❑ All vegetative areas payable to Dane County Zoning. The fee for ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is ❑ Topographic data(2-foot contours) non-refundable. I,the undersigned,hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I further certify I am the property owner,or a duly authorized representative,and may sign this permit application on the behalf of the owner(s)of said property. Applicant signature: \ykk,� CJ;•2J 'Date: [ H:\Zoning\Shoreland-Wetland Zoning\Chapter I I Forms\DCPSHL Application.docx Version 1.1 Created 12272013