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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 Perot#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 /> 1/S.S r`7Qiers�'f1 �' 2,e< 61c-- 24r <br /> Addr ss ''// Agent Address.I n <br /> City,State,Zip City,St te,Zip <br /> PIC&4J 35-5-6 wqqviet4ta—, 573-5e777 <br /> Phone <br /> Coe 3/6' Agent Phone 1700-S7�--74s7 <br /> E-Mail `/�` Agent E-mail <br /> r(4 ,e�C'i;-@ c -,2 ; <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> ro�pe-rty,Address� � �� Town/Section Acreage <br /> �iVl <br /> Parcel Number(s) Zoning District <br /> - )C/ p Itiq 7 �a / � <br /> CSM Lot Subdivision Block/Lot <br /> I 1 P;k� rro4- <br /> Project Description <br /> r\42_ _ <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?4rYes ❑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? ONo 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 jitNo <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 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 /> / n <br /> Applicant signature: .%I ,L� Date: 3/�� <br /> H.\Zoning\Shoreland-Wetland Zoning\ hapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />