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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shore land Permit#:DCPSHL- - <br /> Application must be made in person Zoning Permit it 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 /> )ckv- Be: / <br /> Address Agent Address <br /> Nof`['^ SL,e or <br /> City,State,Zip City,State,Zip <br /> BefijlLe \A7 51-S OS' <br /> Phone Agent Phone <br /> E-Mail Agent E-mail <br /> 64.;I j be!ley;/I+Z,.. k .v4.ijs <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Se ion <br /> a- D _ma/ <br /> Nor 51 / - c rose-)LI % NINI 1/4r <br /> Parcel Number(s) Zonin District <br /> 0 S Q 3�l �— C)-4-o I R--1 < `71 <br /> CSM Lot Subdivision Block/Lot <br /> (fie //rose <br /> Project Description <br /> 0\,(3)Cj S <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?,k1 Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property?.9 Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? QINo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes WINo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes Ai 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\Chanter 11 Forms\DCPSHL Apolication.docx Version 1.1 Created 12272013 <br />