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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#Dt:PZP- 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 il; •lt_ X06 1 2vc r Da2m+' "f . mss A'er 2 c /ve4R.1IrAS Address Agent Address 11 ho ate i. LCZb i..1■) ivieCAA 1.00f-s City,State,Zip City,state,Zip 1 ©SS,t.f-1. A. t 017.1 � 1i12 ..473..473 c- Phone Agent one ' f ,jl�i} ‘3 o -- ` '771 - w ,1 B - w5---- -g z -Mail Agent E-mail L 4rtGg"v5 ,t tea'9 /j atita5 oc4 ti H4ai-f OricitS'1471Q Conn Property/Location Information (http://accessdane.co.dane.wi.us) Property Address Town/Section Acreage Parcel Number(s) Zoning District A /06 t0 —O)- -Co D3 - 27 CSM Lot Subdivision Block/Lot ivi9.- v CA- R; .,.y I Project Description 1Q Doo a 13 O 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? 41 Yes ❑No ❑ Don't Know Is there a wetland or floodplain on or near the property? ❑ Yes ►�,t'o ❑ Don't Know Is this project associated with a recent rezone/CUP/variance?ikiNo If yes, petition/appeal if . Is this permit to correct a violation? ❑ Yes Io Have you contacted the Dane County Land and Water Resources Department about this project? ite 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 ❑ 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. 1,the undersigned,hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I further certify t am the property owner,or - :• f :i .orize• : -sentative,and may sign this permit application on the behalf of the owner(s)of said prope• Applicant signature: _. Date: ,t'" 3ca--e'y HAZoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSkII,_Application.docx Version 1.1 Created 12272013