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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 I <br /> Address L� D Q� Agent Address) <br /> \vor�Z .Coo L-1,,c fe� <br /> a 3 ,S61,,>� A r 0 71 /-) S( <br /> City,State,Zip City,State,Zi <br /> S'f-o IN6 n L,)1 S.3Sgi S , -40,, wm S35.S`i <br /> Phone J <br /> Agent Phone�_ 5s7 9 4/9.9 O p 873- 9E/8 r <br /> E-Mail <br /> Agent E-maili,(' ( J J II <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Tow Section Acreage <br /> ao 3 SIC3(1 e_ /fir, v, %% 1510 „ <br /> Parcel Number(s) ' Zoning District <br /> 04(o/0611-ago yas1-o <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> Add .'/')o -1-0 e)e. -4 d���I �Gly, <br /> Please answer the following questions to t your m e best of v ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake?y1 Yes ONO ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes 1iNo ❑ Don't Know <br /> Is this project associated with a recent rezone/CtJP/variance? ❑No If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes P No <br /> Have you contacted the Dane County Land and Water Resources Department about this project?IN 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: Date: —c?,4'-ao 10 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />