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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Pernut#:DCPSHL- 16- 1 <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 /> 4 4 1 6 *J a i ..1;- iv LhC fo e( I ztvf Sf-,elei <br /> Address Agent Address <br /> zo9c y41c brave 14114 S rorl sa- <br /> City,State,Zip. City,State,Zip <br /> S ✓ (VI 535,7 ale504 vi t 6--- ‘75"--6--- ‘75"--Phone Agent Phone <br /> 608 23 l , 9c / $- y s 64 <br /> E--Mail /�/�/�/�)rail, 'A Agent E-mail �/►(� yyw�, <br /> CU 11-t Ci-.1ro p SO/f .e Oi4 &1 f%Cv1 f U 8 v`.'1'( e A' <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage Z <br /> IA %IA <br /> Zo 11y/ nZ- iN v� fi sa„ur5/12 ag <br /> Parcel Number(s) Zoning District <br /> Se z9 -6-1/ Pier Gott 4.97 J NW let Co./ • , R-Z, c f rzg -ZO i3-/OC i s" <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> icr de 411411V0 r-ae. /c hiA/ o;-- - <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? IV Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes'Wio ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?I<No If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes Q�Io <br /> Have you contacted the Dane County Land and Water Resources Department about this project?( Yes ❑No <br /> C <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- ore . • ning permit and certify to the accuracy of the information. I <br /> further certify I am the property owner,or a d.y authorized reps: entative, and may sign this permit application on the <br /> behalf of the owner(s)of said pro. rty. <br /> Applicant signatur.: J"`' Date: ' av <br /> /‘ <br /> H:\Zoning\Shoreland-Wetland Zoni • aster 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />