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Dane County Shoreland Zoning Zoning eke 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 /> '5I,t4e. `96cf. '647, 14444- <br /> Address Agent Address <br /> 121A9 li(O4'Ltv& `4 `l3 , 5 Mi 5ckedt I'-d <br /> City,State,Zip City,State,Zip <br /> Skikl*0n WA C/72 5°0� SA-oJ In n w 5', c <br /> Phone Agent Pho <br /> CWT) 331{' 'Pill- (r900 9-175 - (-114I <br /> E-Mail Agent E-mail <br /> nkzd.c_ VG, tkt.I�IZ \k,, Oak*,1/1An,nc. e pvti.tCrsirtc.ne <br /> Property/Location Information (http://accessdane.co.dane.wi.us) l <br /> Property Address Town/Section Acreage C <br /> 1254 ?ifetkk11119( "('D6NgIO - /is 'Sit) %% SE , W l5 <br /> Parcel N mber(s) Zoning District <br /> 011 0610 — 1*(79 - 5 g-3 moo - 50 t$1 <br /> CS ` f Lot Subdivision Block/Lot <br /> �m 1 (.81JW\1?f(7� tp <br /> Project Description f <br /> Ito; Ind vNCCA11s <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? ❑Yes ONo ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/varianceNo 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 /> Li <br /> 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 o erty. <br /> Applicant signature: 6 `" Date: —7 /_ / 7 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />