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Dane County Shoreland Zoning Zoning office use onty <br /> Permit Application Shoreland Permit#:DCPSI� {`7 - 6 °I <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 /> David Casimir <br /> Address Agent Address <br /> 4197 Barlow Rd <br /> City,State,Zip City,State,Zip <br /> Cross Plains, WI 53528 <br /> Phone Agent Phone <br /> 608-662-1277 <br /> E-Mail Agent E-mail <br /> dacasimir @casimirjones.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 4197 Barlow Rd Town of Cross Plains/17 1/ NE 1/4% NE 27.9 incl. ROW <br /> Parcel Number(s) Zoning District <br /> 020/0707-171-9561-0 RH-4 DCPREZ-0000-05757 <br /> CSM Lot Subdivision Block/Lot <br /> 07349 1 N/A N/A <br /> Project Description <br /> Construction of a storage building for a residence. <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? 8 Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? • Yes ❑No ❑ 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 •No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑Wes ❑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 . .p cation for a shor nd zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property • ne,,or a duly auth 'z repr se ative,and may sign this permit application on the <br /> behalf of the owner(s)of sai• • ope . <br /> signature: tti 11 Date: 1 <br /> H:\Zoninc\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />