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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Sh 16 Q <br /> oreland Permit#:DCPSHL- - 1 <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 Name <br /> Jim Cisler Rob Montgomery <br /> Address442 S Burr Oak Agent Address 119 S Main St <br /> City,State,Zip City,State,Zip <br /> Oregon, WI 53575 Cottage Grove, WI 53527 <br /> Phone608-835-7705 Agent Phone 608-839-4422 <br /> E-Mail, Agent E-mail <br /> jim.cisler @frontier.com rob @ma-rs.org <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section <br /> 3051 Shaw Ct ,, NE ,%,,%,Sw Acreage <br /> T06NR10E/S5 0.358 <br /> Parcel Number(s)028/061 0-051-4474-6 Zoning District R-2 <br /> CSM Loth Subdivision Block/Lot <br /> Waucheeta <br /> Project Description <br /> Residential lot <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? III Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? I 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 BNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes 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: //,__ <br /> ___, Date: /l- Z — /t4 <br /> H:\Zoning\Shoreland-Wetland Zoning',Chapter 11 Forms`'DCPSHL Application.docx Version I 1 Created I/77/013 <br />