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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shore land 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 <br /> Side Do.b.c, <br /> Add ss Agent Address <br /> / 011-1-). (— <br /> CittRte,Zip City,State,Zip <br /> Phone Agent Phone <br /> go d S-7-1 - C n <br /> E-Mail Agent E-mail <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address / / y Town/Sectio/n. ( om y� Acreage <br /> Parcel Number(s) Zoning District <br /> ) �Ll � &y br <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> �Pa,r/rtplo,0-<__ ('e-ko. s wo.ii ( rn <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? Of Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property?k Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? ❑No If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes'1 }No <br /> Have you contacted the Dane County Land and Water Resources Department about this ' oject? ❑ Yes fa <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. <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: <br /> H:\Zonina\Shoreland-Wetland Zoning\Chaoter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />