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Dane County Shoreland Zoning Zoningofce use only <br /> Permit Application <br /> cation Shoreland Permit#:DCPSHL- / Q <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 /> Narrwm / Agent Nang <br /> Ad rd'ess c n i S e Lc fri t // do rt �j/� '-s e- 1 <br /> 7 ?g z S (:7/, RJ tCled25 s1 <br /> City tate,Zip City, tate, <br /> 6fl vrt To 414 W/7 5-35 l`5e9P1 570 <br /> Phonor Agent Phone <br /> 0 t 3-5-g" 25-.X6 60 -/..3" 1/7 3S-- <br /> E-Mail Agent E- it <br /> va/lec VI Q 0— n e Aorti mfr.( / Q � ?P1 cd'k <br /> r � �' <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> P5o 7'perty Address Town/Section Acreage <br /> 3 7� �or�nDr, 10 p v. %% <br /> Parcel Number(s) Zoning District <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <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?KYes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property?Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? ❑No If yes, petition/appeal# J C 71 <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 ❑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 /> ❑ 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 /> Applicant signature: Date: <br /> H:\Zonina\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Anolication.docx Version 1.1 Created 12272013 <br />