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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 <br /> .,.\(44t4 ,Ande►�or,-rr�st On <br /> Address Agent Address <br /> d315 (ADi l I Ixvmslol n-t-br► W. <br /> c. L, City,State,Zip <br /> C4 911410r) ) (. .YT. 535 201 . <br /> Phone Agent Phone <br /> 315 - alto - fog(0ho <br /> E-Mail. Agent E-mail <br /> j QM3ersora 00 19 ® yahOO .(on, <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> dN5 1 11 I I farts'Polvtt Uy. S+ouq hbr s % %% <br /> Parcel Number(s) Zoning District <br /> CSv, Lot Subdivision Block/Lot <br /> Proectescription <br /> En art ne7 tr■dge Ron, LArta -b Top of ,oat house , replace <br /> er��- tb e <br /> f 0 ' . 4 , o C •lJ • r1 , LLG ea tik,. 6t).l <br /> Plearz c a.-:s _ c 'c:'owing 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? ®.Yes ENo ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ENo i$ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? tiallo If yes, petition/appeal# . <br /> Is this re:. :o correct a violation? ❑ Yes f No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? Re Yes ENo <br /> Most applications must be accompanied by a survey showing the following: <br /> z Pr oerty lines with dimensions <br /> z A. ;,tiisiin structures Permit Fee due at time of application <br /> An n Please have cash or check payment available <br /> a A1' 1 N ijag. zici s"'"'�` at time of application submittal. Checks are <br /> ? ari`e areas payable to Dane County Zoning. The fee for <br /> y •�h W ter Mark a shoreland zoning permit is $150.00 and is <br /> z %r:ngr d ta�( � ) <br /> To_oo�ru.'i h' 2 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 c �ti�► o owe Q,[�sftllti�,tho�zed representative,and may sign this permit application on the <br /> behalf of i 1 TT��UU��JJ��YHU / <br /> Applicant signature: y ' 1(,*S� Date: <br /> El:\Zon:ns S'-,--co d-w eaand Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />