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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- - <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 /> me . �-- Agent tspe <br /> k34fr Se 'Cfit. Dr 1 !', re(u✓1 t-.. ; it ( . <br /> A d5t' woo) 1114/1 D . Agent) s �lAr( �t koo/ gy <br /> Cit , t te,Zip City, e,Zip L <br /> '�1& o , ] i . 665 `I5 d �� rl ih t W. �3SSfr <br /> Phre3O_ q l � � �0 A anvV\ 62 Ni a k V' <br /> E-Mail P1 Age 1mail L <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> P rt Vd re A TQwn/Section1 <br /> 1J V N Acreage <br /> ■ <br /> Parcel Number(s) Zoning District <br /> ©cl�rn� �3y� 4/110C)-7 , �3 <br /> CSM Lot SubdiysioOn I � {I n l „ � � �� Block/Lot <br /> Project Description <br /> C -- /—` (Zq c,,c . „ tv., (— / q )( c.,) ... <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 pond or lake? ■Yes No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property?1 Yes No Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? I"IgNo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes tfiNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ YesNNo <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 sai property. C 1 <br /> Applicant signature:_ a/W\ `k1 Date: v I ^ / 7 <br /> H\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />