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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 /> 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 /> N � ( te 1 Agent Name <br /> e a <br /> AddlrreeJesss/ i- Agent Address r. <br /> City,State,Zip City,State,Zip <br /> .5+0 u (A 5 3 S S 9 <br /> Phone Agent Phone <br /> O?— 414/44 'Z 3 3 <br /> E-Mail 1 { Agent E-mail <br /> b - i a Le-A-C C_ vl I <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> /96y 1?4f1L.ce- -r. vN '1'/ ag <br /> • <br /> Parcel Number(s) Zoning District <br /> CSM Lot I Subdivision Block/Lot <br /> Project Description <br /> d >>r1 -A>r, /0(Abe <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 71 Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ❑NoRiDon't Know <br /> Is this project associated with a recent rezone/CUP/variance?XNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes'No <br /> Have you contacted the Dane County Land and Water Resources Department about this project?gI 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(s)of said property. <br /> Applicant signatur•. - Date: 6 7 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />