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Dane County Shoreland Zoning Zoning office use onbr <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 /> Nam:, Q Agent Name <br /> Address Agent Address <br /> O 3YQ f t1lA 'tS 10 tit rtJ Ci <br /> City,Sate,Zip C•iTyte,Zip <br /> e ki d o si se Lrv' <br /> Phone Agent Phone <br /> is <br /> E-Mail Agent E-mail <br /> 424 I ead g,-3 At it . G d9.i4 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Ad�df esis Town/Section Acreage <br /> 02304 1i/,j1 t4 8 id[iti v, <br /> Parcel Number(s) Zoning District <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?X Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ENO Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?tiCNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes TX:No <br /> Have you contacted the Dane County Land and Water Resources Department about this project?Ni 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 prpperty 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: /(o d// <br /> H:\Zonina\Shoreland-Wetland Zonine\Chanter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />