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Dane County Shoreland Zoning Zoning office use ono) <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 /> , q. •s - <br /> Addr s Agent Address <br /> t _ 5 SIR 411- <br /> City,State,Zip City,State,Zip <br /> V -ell'9 Alin, <br /> Phone Agent Phone <br /> k3� <br /> E-Mail Agent E-mail <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section A 3 a <br /> % % <br /> ? <br /> ( S?/ �'�` ms-t. 11 .� <br /> Parse umbers) Zoning Distr' <br /> cs <br /> '03 0-1 111 ' S 11 •-��X <br /> YN/N ^ Subdivision Block/Lot <br /> Project Description U <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 1akeYes ❑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? ❑ Yes 10 <br /> Have you contacted the Dane County Land _and Water Resources Department about this proj t? e ❑ <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 infofmation. 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:\Zonine\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Anolication.docx Version 1.1 Created 12272013 <br />