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H4 sr liv,r c i `' <br /> Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit If:DCPSHL- /6 - /7 <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 <br /> Nam <br /> Address ion k N ecz <br /> �1 (i� \la <br /> Agent Address <br /> 4 13 Cos mit bri\f e 5� 3;t rit 1A/ I <br /> City,State,Zi City,Sta e,Zip <br /> etILISW■ WT 5 37/7 Phone ) Agent Ph + <br /> f ox 277- 31-o 0 3j�/�06+ 4-35o _ <br /> E-Mail 1 1 AgentDE-mail <br /> kier,,Sc M cr-(_-, t-thk Vo c,/<0 /401)0e4rAiTiO4•Cd1Wil <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> 0 Address � TowNSecti/# Acreage 5 <br /> r <br /> Parcel Number(s) /,�, Zoning District <br /> 0512 1 /�g0(d0 7 <br /> CSM Lot i. Subdivision Block/Lot 7 35 <br /> Project Description <br /> H e.,' c, <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?*Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes)1No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?XNo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes ko <br /> Have you contacted the Dane County Land and Water Resources Department about this project? Yes ENo <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—S 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 oreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property owner, or a duly a horized representative, and may sign this permit application on the <br /> behalf of the owner(s)of said party. <br /> Applicant signature: Date: ''AS i 4 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />