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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 /> Name p� <br /> C.-koA c-oi ( ±LUJr - Age\T�Gir �I /9 ( rJ� ik at. t,�,� t <br /> Address A ent Address <br /> f 7-a- Oct (r-,,'( �,('- -3`-( (,) . IBC(--t Li S1— <br /> City State,Zip City,State,Zip _ <br /> ,c...S L✓r 01 l g (v LAkL 4-?i`- C J S3 v 9 <br /> Phone Agent Phone <br /> sg- a6 -7ati) <br /> E-Mail Agent E-mail cAI <br /> p-te� � eiM �r� ( we t . CO1 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> l3a14 oC - C 1 rt mac_ , <br /> Parcel Number(s) Zoning District <br /> 061 / Sa ) c, R 03 <br /> CSM Lot Subdivision k�Q /p / Bloc � <br /> D — <br /> Project Description <br /> 5-1'P <br /> Please answer the following questions to the best of your ability: 1 <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake9,.�J Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Ye$10 ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?so If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Ye E/C�No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes <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 /> to <br /> 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 /> o 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 signature: Date: I 1 <br /> PP g <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />