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Dane County Shoreland Zoning Zoning office use on(v <br /> Permit Application Shore land Permit/l:DCPSHL-1 - JO <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 N me <br /> Cf r: 1 Pe bade, 1-1,Aciar, )- _uJe 6o>-,j- i/C <br /> Address Agent Address I \ <br /> is vicud,,eztf, Tr. 1 `--; L <br /> City,State,Zip City,State,Zip <br /> M AOI ao.. X11 S3 � i x �lt\ S o3-G <br /> Phone Agent Phone <br /> qc # <br /> E-Mail Agerrt E- ail <br /> dA a�� Scc. . co ' <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> / _ 1 �(�) 1/4 1 1 <br /> vAn/� // S <br /> Parcel Number(s) ) Zonin s.tri <br /> )5 q" WC) e � <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? ❑ Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ❑No LI 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? LI Yes ❑No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ 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 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:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />