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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 S 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 /> Chad Scott Hart DeNoble <br /> Address Agent Address <br /> 3083 Lyman's Run 7923 Airport Rd. <br /> City,State,Zip Sun Prairie WI 53590 City,State,Zip Middleton WI 53562 <br /> Phone 608 220-1211 Agent Phone 608 831-4422 <br /> E-Mail Agent E-mail <br /> chadscott @firstweber.com hart@denoblebuilders.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> t3o K�fo If ))1/%0,1401 r f)(-51'6 v. v.v, <br /> a <br /> Parcel Numbers Zoning District <br /> 0911 3o - oW 9 G- 0 n 0 <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> new single family home <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? a 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 BNo <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 /> Li <br /> 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 /> Li <br /> 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: <br /> H_A Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application doex Version I I Created 12272013 <br />