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Dane County Shoreland Zoning zoning office use oniy <br /> Permit Application Shoreland Permit#:DCPSHL- - <br /> Application must be made in person Zoning Permit it 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 /> /PICM6GG6s Nick A1 6--1E12 rlKdrEg/kSto Z6- <br /> Address ' Agent Address <br /> 5375 CFA/ K 038 S,l'K 41)66r Tk <br /> City,State,Zip A City,State,Zip <br /> CO SS- PC/4i s 1 tO I 53 5Z8 /11/90/5-0ti , GU s"/ 3 7/ 7 <br /> Phone Agent Phone <br /> 60 F,' ' ( 7cf ' 3830 60E3 , zi '' - o 90 — <br /> E-Mail Agent E-mail <br /> rn1CH6Z 66-04/3k//)666/Z e- e uv/6, (tic 114-5A/4 coerz-L& cs*I. i27-75-72 ,xx 6—T <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 637? C%I/ K1C,eOSYPL, GJ/ 86FRR y/19- 'r.i(lWr.y4 Nit <br /> 3s- <br /> Parcel Number(s) Zoning Distract <br /> 604 f OS 07 -142. 5551' 7 A- / (6x � <br /> CSM Lot Subdivision Block/Lot <br /> /6/4. AU A it.)A. ,o1 <br /> Project Description <br /> NS-td c 4 k.l¢G 6 <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 ($1 Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes KINo ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? XINo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes ri:INo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes NNo <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 /> f ,. <br /> Applicant signature: / Date: 4`z 17 <br /> H:\Zonine\Shoreland-Wetland Zonina\Chanter 11 Forms\DCPSHL Anolication.docx Version 1.1 Created 12272013 <br />