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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL-I -7 - 3 C <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 /> ini, <br /> l. 1, Agent Name <br /> l. "�- ,' a ro_ 4C 1 Al Agent Name <br /> 4105 7 �,K-\J l�-.�� tr. <br /> Agent Address <br /> City State,Zip t City,State,Zip <br /> Ik-A-oK., 1,t21 6'g9 <br /> Ph Agent Phone <br /> o L05— 558— B4'31 <br /> E-Mail Agent E-mail <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address own/Section Acreage <br /> 01067 Nil, br- 41(.4A1 —%%— <br /> Parcel Number(s) ng District <br /> 0611 q,qV 3 -� <br /> CSM Lot Su4division Block/Lot <br /> Project Description <br /> t,)i-k- <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 El Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑Yes JNo ❑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 f/ INo <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 /> to <br /> proposed structures Please have cash or check payment available <br /> o 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 thorized representative, and may sign this permit application on the <br /> behalf of the owner(s)of said pr petty. <br /> Applicant signature: J (A)LCL.' Date: 40 <br /> H:\Zoring\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />