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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL-1 7 - O T <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 /> Nile Agent Name <br /> Jae Ulll--V Add ,q-),64 a-C.. 'ftillt 61— ' ° <br /> Addres / Agent Address <br /> 300 e--41677—i17 Ai 5l<0G <br /> City,State,Zip City,State,Zi <br /> 5at.° PJ i21 _, t) ( o <br /> Phone Agent Phone <br /> (,g.--cep-y -5--0 <br /> E-Mail Ag nt -mail <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section (/�� Acreage <br /> �d-6�o �ro j.'„� tiJ� mod', <br /> V / \I X1 4 �%14 <br /> Parcel Number(s) / Zoning District <br /> 0q1/ 3o ).- - nsi & 0 <br /> CSM Lot Subdivisio i Block/Lot <br /> Project Description <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? Z Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?1 'No If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yesp'\To <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes io <br /> Most applications must be accompanied by a survey showing the follow ing: <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. <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: !/`"g"--71/ <br /> H:\Zonine\Shoreland-Wetland Zonina\Chapter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />