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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shore land Permit#:DCPSHL- l-2- ■SC <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name , , Agent Name <br /> Da ilti t Zi I tr\. <br /> Address Agent Address <br /> via5 b1, 15A . <br /> City,State,Zip City,State,Zip <br /> �/Yla Isew , („O 5 7O(4 <br /> Phone Agent Phone <br /> q <br /> E-Mail Agent E-mail <br /> aill elie kezda—@ c - -. , f <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section <br /> y <br /> ecction Acreage <br /> 4)(4 'wi Parcel Number(s) Zoning District <br /> ON/ 0$I6— W4.-NI O 1:B g--'' / 1 6G <br /> CSM Lot S divisio Block/Lot <br /> I 1Onum ./(ilti J <br /> Project Description <br /> s1-' w De_c_11 <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?X Yes No ❑ Don't Know <br /> Is there a wetland of lloodplain 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# . <br /> Is this permit to correct a violation? ❑ Yes. o <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 of said property <br /> 1 <br /> Applicant signature: .L. Abl► 'L Date: 5;3—1 1 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />