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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- f - <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 Nam <br /> Cat 6`' 64't 1 Illt ?f c a✓l rot\KO1{/w VV(Mr■1\ <br /> Address U ,J Agent Address <br /> b 12 Sh ln S+ R `N C477I.5 jvho(A <br /> City,State,Zip ` r/2-2G �c q City,State,Zip \-11A-OQ5V1\ 311 1 VA U I ��6J41\1 , 17i 5(3(A <br /> Phone Agent Phon 1 <br /> (o - (6-17 - (9 0 ((;90) 21)(7 - c� <br /> E-Mail Agent E-mail <br /> �h".?c d l� 32b a cent,,,)-ti. ��+- M& - \-kvy\,iN(i, 1/1.Y� <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section `A, L Acreage <br /> ?�o12 ShctX1 s∎ � Tr roceNg-11E / �O ��4s " 1�4% S � o • t o <br /> Parcel Number(s) Zoning District <br /> 011CO/IUD 11 -7)o14 - 1- 7A) <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> pi"t64-0 \ fs I k � ��r'(' , - ' r (( G�;v�� v,1fi�1 iv1S�-c,( � �1 <br /> ce l I r T t c� t-.-^1 S v V\S-/\ <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? LX.Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes gNo ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? tcNo 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? gYes ❑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 owners)of said p •• <br /> 11I Date: <br /> it°11(P <br /> Applicant signature: <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />