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I-1 o ,. ( 5`!o Øy <br /> 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$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name <br /> 3 f—FEay.13AR,3kgA ScfIvE7-z 404A7 e,fRIV —&■Ma5d Ace CMrL_� <br /> Address Agent Address <br /> /02.2_ E. LifIKE- ✓ g ik'. /09 2 A'1i<,�„�v�t c S7 <br /> City,State,Zip City,State,Zip <br /> E c aro.v, r-✓T 5.35-3 11 '4.vE-s rr«E, Ali S3Sy8 <br /> Phone Agent Phone <br /> 60e-ZiZ-g 06 7 6013— 752—DS7S <br /> E-Mail 11 Agent E-mail <br /> eT <br /> jeSC +v G rt4C2n ►S . CoM a. , PPt n@eo.+,bssorttey, Cowl <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section S 1/Z v E / Acreage <br /> ZOO 1-I ∎)IS;4e R . 5N/ /`i/ " '%% v 24437 - <br /> Parcel Number(s) Zoning District D G PRE.Z <br /> o511.- 11-1441} coo 4- . (zoiS — <br /> CSM Voa.q$,P 112 Lot Subdivision N/A Block/LotA <br /> 1� I•) • <br /> D.SZ7Z53 Z <br /> Project Description <br /> Co•vST•¢�Tion� <br /> oF 01)Eaii /%Avi DE 644rE-4._AO/1/-.4.,/.<1y(,4ccess Fi&o 1 Niu-Sidi-gc.q )?L� <br /> hN 41/t.EA r•/,Thin/ 300'DP ,41 CE c-•9 KE. <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? Ye <br /> LJ s ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ❑No E Don't Know Pc.45,d 4i pe r JNR S t~/b V ivi p� <br /> cookriNQA <br /> Is this project associated with a recent rezone/ UP/variance? ❑No If yes, petition/appeal# I Ci Lf <br /> Is this permit to correct a violation? ❑ Yes <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 Cs.7v1 <br /> Ia"All existing structures No NE Permit Fee due at time of application <br /> V Any proposed structures seEV`.►nrs Please have cash or check payment available <br /> All impervious surfaces •� at time of application submittal. Checks are <br /> I]�All vegetative areas payable to Dane County Zoning. The fee for <br /> I�Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> 4/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. j <br /> Applicant signature: ��.� ,� , A ' Date: 3/ /201 7 <br /> >/ / t, / <br /> H:\Zonin,\shoreland-Wetland Zonin¢\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />