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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 /> Shore land 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 /> P . .Pr Je,25'/1 <br /> Address Agent Address <br /> / q/4., 2_ Qua/y, / P. <br /> City,Sta .-„Zip Zip City,State,Zip <br /> Jt-GU tiion wl s? Se? ? <br /> Phone Agent Phone <br /> 6o i- a35 'c <br /> E-Mail e i Agent E-mail <br /> V 7' .‘,7 SY 6 b v.{r7serl L@ GG/ revr? <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> Vi om. ()± P %% <br /> Parcel Number(s) Zoning District <br /> Cc/ -a s33 0 3L-f g I-- <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> 9 c\--r kal - 1„10,) 1 uv-toc, <br /> Please answer the following questions to th best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake?cg Yes No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes'F\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? ❑ YeskNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes 131■o <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: V4 7 <br /> Iiir <br /> H\Zoning\Shoreland-Wetland Zoning\Chapter 11 s\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />