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Dane County Shoreland Zoning Zoning office use onlv <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 Nape <br /> Kieran Montgomery �o - /.a_ <br /> Address 1172 Maple Grove Road Agent Address <br /> City,State,Zip Stoughton, WI 53589 cityCc�tat�} �r (,u_ , 53 S'27 <br /> Phone J Agent Phone <br /> (608) 225-4421 6 0 y - 7 i-0(2_2_ <br /> E-Mail Agent E-mail <br /> keran@ctwflooring r- e ,t,t c, r-s. 0 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 2187 Colladay Point Dr Dunn/23 % SE y y4 SW .30 <br /> Parcel Number(s) Zoning District <br /> 060123446805 R-3 <br /> CSM Lot Subdivision Block/Lot <br /> Colladay's Point 60 <br /> Project Description <br /> Construction of a single family residence <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? 8 Yes ONO ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes UNo ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? ❑No If yes, petition/appeal#937 <br /> Is this permit to correct a violation? ❑ Yes •No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑des 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 •my a orized representative,and may sign this permit application on the <br /> behalf of the owner(s)of said property. / <br /> Applicant signature: �� Air Date: • <br /> H:\Zoning\shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />