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Dane County Shoreland Zoning Zoning office use ony <br /> Permit Application Shoreland Permit#:DCPSHL- r7. '.1 <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 Nam / 14 <br /> & brt Cote Z <br /> Ad As / Agent Address <br /> 3>ii h ei vl c� S g 0-6 coves c_f ill z <br /> City,Statp,Zip �^ City,State,Zip / <br /> Co tt S e Ere Z )I e '3�r; frodrr l01ac- (t).l- 5-3�b 7 <br /> Phone Age Phone <br /> 97x- 6cc (' 6°S) 01d '—sr 4 <br /> E-Mail Agent E-m ' 04 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address L T /Sectio Acreage <br /> kCIr Oil wv� r/ 4 .1/4 <br /> NCI i1 <br /> Parcel )U 56 7-0 Zoning District '3 I! &'t L Sti -e <br /> CSM Js! a lLJot Subdivisio ////!1' 1/ Block/Lot U <br /> i ' (I&/I.QV <br /> Project Description <br /> lit) C, ■I <br /> Cb51OvN <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 pond or lake? ❑ Yeo ❑ 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/CU /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? ❑ 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 s • - and zoning permit and certify to the accuracy of the information. I <br /> further certify I am the pr.: •wner, or a dul . thorized representative, and may sign this permit application on the <br /> behalf of the owner(s) •f said p operty. <br /> Applicant signature: Date: /1 /1 7 1?O( <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />