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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL /6_ G <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> C — X16- 17s <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 y))1241ANoil Agent Name <br /> 104 MON 1C)R-KLL3ow aC-C,0v/21 <br /> Address Agent Address <br /> yaks' efid AD <br /> City,State,Zip j City,State,Zip <br /> CAWdtc P4401,1/5 J <br /> Phone Agent Phone <br /> 6o13 793 086-r <br /> E-Mail Agent E-mail <br /> /'Ac(TaF AKac)•GoArt <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section y, S(�l +�.%. � Acreage <br /> cA� <br /> >� &7 cg0y3 /7 <br /> Parcel Number(s) Zoning piltrict <br /> 0/0 7 ?3� 5716"— cy R//'7/ <br /> CSM Lot Subdivision nBl rK/L <br /> 00 36 <br /> Project Description <br /> G.C")N 4-‘/\4-/ <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 Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ❑No ❑ 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 [/ lo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? C''es ❑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 /> Li <br /> 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 signatures. Date: <br /> H:\Zonine\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL An lication.docx Version 1.1 Created 12272013 <br />