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7,ei Dane County Shoreland Zoning <br /> Permit Applicnn.4 <br /> Application must be made i rson P c+ <br /> Shoreland Zoning Permit fe is$150 <br /> A shoreland zoning Permi • e 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 /> Jack and Georgia Lazzaro <br /> Address Agent Address <br /> 1994 Selkirk Ct <br /> City,State,Zip City,State,Zip <br /> Inverness IL, 60010 <br /> Phone Agent Phone <br /> (847)830-7243 <br /> E-Mail Agent E-mail <br /> Jack_Lazzaro@ajg.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 3392 Quam Drive Town of Dunn/25 '% s"' '%% "w 0.43 <br /> Parcel Number(s) Zoning District <br /> 0610-253-3120-1, 0610-253-3109-6 R-3 <br /> CSM Lot Subdivision Block/Lot <br /> N/A 9,10 Ouam's Park,OLE J,Addn To N/A <br /> Project Description <br /> Reconstruction of home,garage,concrete driveway,and bio-retention device <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? IR Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? IN Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? BNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes BNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑'Iles ❑No <br /> Most a. lications must be accom'anied b a surve showin! the followin•: <br /> ❑ Property lines with dimensions <br /> la <br /> existing structures Permit Fee due a ime of a •lication <br /> ❑ Any proposed structures Plea = ve c.sh or c e '. •• = e <br /> ❑ All impervious surfaces time of application submittal. Checks are <br /> ❑ All vegetative areas payable to Dane County Zoning. The fee fo <br /> ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 is <br /> o Topographic data(2-foot contours) 'on-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 pro.-rty. <br /> Applicant signature: ,A W:w ' Date: I L, '.' <br /> i <br /> H:\Zoning\Shoreland-Wetlan. Zoni :\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />