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Dane County Shoreland Zoning Zoning office useonly <br /> Permit Application Shoreland Permit#:1 S13I,- f <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 /> Vern Stenman <br /> Address Agent Address <br /> 1417 Morrison Street <br /> City,State,Zip City,State,Zip <br /> Madison, WI 53703 <br /> Phone Agent Phone <br /> (608) 575-4267 <br /> E-Mail Agent E-mail <br /> vernstenman @gmail.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 3363 Fish Camp Road 28 % sw �4 1/a N w 2.43 <br /> Parcel Number(s) Zoning District <br /> 0610-133-8560-4 R-3 DCPREZ-0000-00363 <br /> CSM Lot 2 Subdivision N/A Block/Lot N/A <br /> Project Description <br /> House, deck, and driveway construction <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? B Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? B Yes ❑•o ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? BNo 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? ❑fires ❑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 /> at time of application submittal. Checks are <br /> ❑ All impervious surfaces <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:\Zonine\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />