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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHI� ►7 a <br /> Application must be made in person Zoning Permit#DCPZP- <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name <br /> ,vf oLF' James RoPteircre S tiC. Howe ascrkbre, mil. 0. Vie. <br /> Address Agent Address <br /> 3S 1444C A% p v t i.i i• r?1 eg s C 4 <br /> City,State,Zip City,State,Zip <br /> /'Ab$Soea , t4 y"37rf Qotost7re , Al= c.,fri <br /> Phone Ageht Phone <br /> 0305) — A/7{" 7y00 6.0 - rT e - 3J t 3 <br /> E-Mail Agent E-mail <br /> SN4.1Jx i-lo&fts c toss+ .ivrr /'7icm.4+r'.rtd'eg ooa l # O ea,' <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section S: Acreage <br /> dg� % %% . 193 <br /> a1 3L hron) rsit AVE <br /> Parcel Number(s) Zoning District <br /> /m61 b ' © "' I I I <br /> CSM Lot Subdivision Blockilot <br /> t 1.4.400 e - t3rRcii . a.+0 Aor <br /> Project Description <br /> 1 Q Dor+W eiFr$utG D S R <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? x.Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? (j No If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes gNo <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 /> a Property lines with dimensions <br /> a All existing structures Permit Fee due at time of application <br /> Any proposed structures Please have cash or check payment available <br /> o All impervious surfaces at time of application submittal. Checks are <br /> a 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 /> a 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: -/•f9- /7 <br /> H:'•Zaning'.Shoreland-Wetland Zoning,Chapter 11 Forms DCPSHL Application.docx Version 1.1 Created 12272013 <br />