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Dane County Shoreland Zoning Zoning office use only Permit Application Shoreland Permit#:DCPSHL- Application must be made in person Zoning Permit#DCPZP- - Shoreland Zoning Permit fee is$150 A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County Zoning Division for any development within the shoreland district. Property Owner Information Agent Information Name Agent Name BRA >-1 G�t>Sl�lZV\ R 1 NA�Z-r DENO 't- 13uIt- Address Agent Address 289 VAI-I-1 1 1Zl OCa r_ PR 1g 2.3 AtRP02T RD City,State,Zip City,State,Zip Sure PRA\2\ t. , W1 53190 ■Iop4--I-Tort v- 1 `5 3S(c' Z Phone Agent Phone (G08) 34-I - 138c, ((,c8) 83i - r'- Z2. E-Mail Agent E-mail Property/Location Information (http://accessdane.co.dane.wi.us) Property Address Town/Section Acreage 2216 CAI-EN G�`K C - SUN ?RAtRiE • '% ,1ZCo Parcel Number(s) Zoning District c sEs i�gll - 343-0523 -v R ( g e o CSM Lot Subdivision Block/Lot ti 3 TKE OAKS Project Description (ZESt DEN TtAI- NEW C.bNST"fzuc-'not Please answer the following questions to the best of your ability: Is the property within 300 feet of a stream or 1000 feet from a pond or lake? ❑ Yes ❑No ❑ Don't Know Is there a wetland or floodplain on or near the property? ❑ Yes ❑No ❑ Don't Know Is this project associated with a recent rezone/CUP/variance? ❑No If yes, petition/appeal# Is this permit to correct a violation? ❑ Yes ❑No Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes ❑No Most applications must be accompanied by a survey showing the following: o Property lines with dimensions ❑ All existing structures Permit Fee due at time of application ❑ Any proposed structures Please have cash or check payment available ❑ All impervious surfaces at time of application submittal. Checks are ❑ All vegetative areas payable to Dane County Zoning. The fee for ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is ❑ Topographic data(2-foot contours) non-refundable. I,the undersigned, hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I further certify I am the property owner, or a duly authorized representative, and may sign this permit application on the behalf of the owner(s)of said property. Applicant signature: Date: H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013