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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shore land Permit#:DCPSHL- '! - <br /> A <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> PP p <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 /> Pqf ib W & > <br /> Address Agent Address <br /> c67 12-v PE-6a ,l) X 06 n> , p&&— bra, <br /> City,State,Zip City,State,Zip /-(- _ 7 <br /> Phone Agent Phone <br /> 60g- Sk7 — S7zo 60g - 2 c- 1'S 7 <br /> E-Mail Agent E-mail <br /> SrO10\84 f Le CJ-t orzuS . NEY 6)Q pq..coly 5 v t CE-sc 6141114 , COW/ <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 6567 V-UP 2 r2-01� we '� 'r. %% <br /> Parcel Number(s) / Zoning District <br /> C • OO► _% I 6o <br /> CSM Lot Subdivision Block/Lot <br /> w\ <br /> Project Description <br /> 5v?Pd►2< Post -C,Ploq -F- SG vj Pow-( ( iari,2-/ &L, F <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?EYes ❑No LI Don't Know <br /> Is there a wetland or floodplain on or near the property? 14Yes ENo ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?ANo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes allo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes 1No <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 /> Li <br /> 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 /> Li 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 ow er, or a duly au orized epresentative, and may sign this permit application on the <br /> behalf of the owner(s)of said pr••erty. <br /> t - <br /> Applicant signature: -/�'' Date: S 2 ) z - <br /> H:\Zoning\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />