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Dane County Shoreland Zoning Zoning office use ony <br /> Permit Application Shoreland Permit#:DCPSHL-I�-- / <br /> Application must be made in person Zoning Perrot <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 , <br /> ,�s f, t'�Z'Ro(ANC Agent Name <br /> �GI�/ Rawzr Det cl,.. 4.4 G►JJr. 4 t Bci... /1.wv- <br /> Address Agent Address <br /> !e .x040 .0 ( Teti"' A k.t-r 7(12-/ vo,sj /1c,07 <br /> City,State,Zip City,State,Zip <br /> 1,14005 v N bG/C 53711 of4s.•A-4.....+ w L X5.3 Cb z <br /> Phone <br /> 4•491? 833 S'�/d Agent Phone <br /> 4,d8 -ZZ.3'- $ Z fit Z <br /> E-//Mail 1 t4 e...y be Q Grf.4 , N&r Agent E-mail �/� /� /y t <br /> 1).Q/II O4.4Y. 0 +Mrs • t!.rN icWeQ rewe0 4-s!',s (Ls?%6T • , r€. w4 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 5/38 167./vac..h. 4tu-e boas r/ r % %% /31 gs, S Fr <br /> Parcel Number(s) Zoning District ` <br /> Peol-ZBy— V29/-S <br /> CSM Lot Subdivision <br /> /OG¢3'o ,Go VG Z Saco,r.a/ul44,r Lis'/O'L/ <br /> got <br /> Project Description <br /> VAertf od t.,.+ra,4 c.- Cs RAw/d' w r rr 4,. 4 (dre. , X. .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?P Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? PAYes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? c3<o 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? ❑ Yes To <br /> Most applications must be accompanied by a survey showing the following: <br /> 9( Property lines with dimensions <br /> .e All existing structures Permit Fee due at time of application <br /> vtr Any proposed structures Please have cash or check payment available <br /> ,r All impervious surfaces at time of application submittal. Checks are <br /> le( All vegetative areas payable to Dane County Zoning. The fee for <br /> i( Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> tde Topographic data(2-foot contours) non-refundable. <br /> Ma copreNAd 4,j Li r' QGeesH!'o:' C/'y' e 2 o+Or 5,4- .4.1 /114.4./ •e4/ f1.no 4 <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 /> fi w lrs.ce4G.+ Lye. <br /> � z ev,t0 �� a» <br /> '/0!" 7 Applicant signature: a Date: <br /> H.\Zonina\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />