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Permit Application friP <br /> Application must be made in person � �� <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 /> Kt'd`1 ki k Vern sk-t . d evil}%--- Gmet.(4 trtpcta-ewarcA6iD <br /> Address Agent Address <br /> 3k03 \(Ct. S1 Cr3 15� <br /> City,State,Zip City,State,Zip <br /> Dv.>\r\ kiJ 1 ►\OLC,c.- - ',t.A-V..l vD <br /> Phone Agent Phone <br /> k 4— Ir.30-- LI Ci 3 cr Vi <br /> E-Mail hr4 PIA Kea PC! o rv+ Agent E-mail <br /> `/C fn tri iitr-r,S iciNe>acil-/Cron .r.--CL US' Ls • (!.r— <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section t Acreage <br /> 33LD 3 sy (a n / S C %J * %% y <br /> Parcel Number(s1 Zoning District <br /> tAp lot3%Stec ` T1M �Cf2— ACx� 3 <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> P{itINCNt`, �+l1VA 1 CbtACk ht m/hteVeySi .ck.1 •CUA bA Vanct. <br /> Ar€kt Stern S% TA,Lir n t`,r bAAsw ` -e (c4 ckvsc - r 10,i,t}sh ( <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?l Yes DNo D Don't Know <br /> Is there a wetland or floodplain on or near the property?'Yes ❑No 0 Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?krNo If yes, petition/appeal# <br /> Is this permit to correct a violation? El Yes KNo <br /> Rave you contacted the Dane County Land and Water Resources Department about this project? KYes DNo <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 /> t#h uriti rstgpj 5#et"eb tisake app)fcation,for a sliaretantI zoning perrrtitand certify to#tte accuracy of the tnforrt a#ion I <br /> -fuller erti ' �p o rtys �r or wally aulhonzed rekpresentative and may sign this permit applcatin on the <br /> L <br /> be)lalf rf"theo 4r(S)�S Id,prope y <br /> �Appt�antslgna : �` <br /> �i � <br /> H:\Zonina\Shoreland-Wetland ZoninelChanter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />