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:IA- 05-I10 4-12-11.2 <br /> Dane County Shoreland Zoning Zoning office use ony <br /> Permit Application Shoreland Permit#:DCPSHL-IG - �g <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 i `_ / Agent Name <br /> Address t Agent Address <br /> City,S te,Zip _ City,State,Zip <br /> JJJ �J <br /> Il"bra.// <br /> Phone Agent Phone <br /> 6 00,1 �j ✓ <br /> E-Mail t;� , Agent E-mail <br /> 10/14 pf (/),- C <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Pro erty Addr ss Town/Section Acreage <br /> 3 dh fU 1V A- :V— i�t 1�103- 3 <br /> Parcel Number ) Zoning District <br /> o-7 0 3 Gavle)9 <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <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 /> • <br /> Is there a wetland or floodplain on or near the property? d Yes EN() ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? o If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes CNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ( 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 application for a shoreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property owner,or a duly authorized representative, and may sign this permit application on the <br /> behalf of the owner(s)of said property. <br /> Applicant signature: ' y�" Date: ''f q <br /> Tx <br /> H:\Zonina\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Anolication.docx Version 1.1 Created 12272013 <br />