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4 ,a , <br /> Permit Application • T ,�. <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 VN <br /> .G1�i tk \)eYn S n jY1 f+ Eie, fi-- t{LAS a- � ' <br /> Address Agent Address <br /> 3 3 \A C cc P-c4 " s! Co $2_D■ <br /> City,State,Zip City,State,Zip <br /> r1 V° i �\a.C-A C I Val S (S <br /> Phone Agent Phone <br /> (O S-- 630--tALict3 t r 1 kPi _'S-5 <br /> E-Mail lwr- i t rt .-i l. tor." Agent E-mail t,. <br /> V;[en 6 mailt�rAs ,IttSe tall_ ttr y { ) Cus° t' -Y "1 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address (�,. Town/Section tr Acreage <br /> aJ3to 3 '►sh (an P (2d e Sec %� �/.%.1`r a.ttif ) <br /> Parcel Numbers Zoning District <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> p-ei t�t ,. \v\Nek t b'A.& N C.buCk ht ►�f hot k U� �(Y�tt i <br /> riNNA.,k,k,ct_teowe itaWsinrov• <br /> Sku-veN %f■ biel...6\r‘ ISi‘' '' r't1.4-' '''' ' <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 ❑No ❑ Don't Know <br /> • <br /> Is this project associated with a recent rezone/CUP/variance? KNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes �No <br /> Have you contacted the Dane County Land and Water Resources Department about this project?KYes❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> o Property lines with dimensions <br /> o All existing structures Permit Fee due at time of application <br /> o Any proposed structures Please have cash or check payment available <br /> o All impervious surfaces at time of application submittal. Checks are <br /> o All vegetative areas payable to Dane County Zoning. The fee for <br /> o Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> o Topographic data(2-foot contours) non-refundable. <br /> n� -roi w3> A , & r3. <br /> #h urld rs n ,ttet b trtake appUca$ n for a shoreland zoning permit and certify to the accuracy of the inform atian I <br /> fume ty im prop rtypWn 'r or adulTauthpnzed re resentattVe and may sign this permit application on the ' :: <br /> beJial ftheQwiier(s) �salrl.prope <br /> , o. Date itt-1 <br /> rAl?pl amnt signal e <br /> Version 1.1 Created 12272013 <br /> H:\Zonine\Shoreland-Wetland ZoninefChaoter 11 Forms\DCPSHL Apolication.docx <br />