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Dane County Shoreland Zoning Zoning office useonly <br /> Permit Application Shoreland Permit#:DCPSHL- tft <br /> Application must be made in person Zoning Permit#DCPZP- - -' [-- <br /> Shoreland Zoning Permit fee is$150 - / <br /> cs <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 /> ,Q4✓/,:j schta4TZ <br /> Address Agent Address <br /> 3232 ,14LSErf/ LAAI.e' <br /> City,State,Zip City,State,Zip <br /> jTot-i&i`/7:041 v/ slug? <br /> Phone Agent Phone <br /> 9Z0 — 7Z 3- 7�3-3 <br /> E-Mail Agent E-mail <br /> 4sseLrzfJx49 e,pit .cry <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property <br /> Address <br /> Town ecttii/`onn Acreage <br /> 3z3402.5.07/14V4' JV,v % 1�4 1�4 ,3/kg <br /> Parcel Number(s) Zoning District v <br /> Z1—o(/t2- 25q- 45.0/ - 5 <br /> CSM Lot .72&/ Subdivision Block/Lot <br /> elf <br /> Project Description <br /> WE,vo✓4?rE p0,9/71a <br /> 11 \ F n / 1 <br /> S>d# ‘,/;40c,./S> re-f46() r�1ec - r";(a..3 �i� l X' 'C°v.i4sl°r. <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? X Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes to ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? to If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes Xj•id <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ YesNo <br /> Most applications must be accompanied by a survey showing the following: <br /> X Property lines with dimensions <br /> X All existing structures Permit Fee due at time of application <br /> Any proposed structures Please have cash or check payment available <br /> X 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: Al.--4444 <br /> Date: S/ZPAP <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />