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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 <br /> Zrffi,4 �vr..�6 7E -r- 72 J am;v.✓ <br /> Address Agent Address <br /> City,State,Zip Ci State,Zip <br /> "7-410 :.<4.4 // 6-37 / r/''g. ( /,‘ "17 9f� <br /> Phone Agent P one <br /> ` 3 1"---i3 - 7' ! - <br /> �� <br /> l� <br /> Mail � Agent E-mail fr2 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 07, 4-/eirrcw <br /> Parcel Number(s) Zoning District <br /> OAF/ '/o -081 -ooa 3 -- a /0-3 <br /> CSM Lot Subdivision Block/Lot <br /> 3 !/54- 4 j <br /> Project Description <br /> ,47r/ /1Irz"1o0 F <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?i Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? El Yes ❑No g.Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?AiNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes'No <br /> Have you contacted the Dane County Land and Water Resources Department about this project?,g'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 contours) non-refundable. <br /> I,the undersigned,hereby make appli . '•n for • shore'.•. ning permit and certify to the accuracy of the information. I <br /> further certify I am the property own, ,or a • au I.. • representative,and may sign this permit application on the <br /> behalf of the owners)of said pro. <br /> Applicant signature: Date: ‘~ 'C <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />