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Dane County Shoreland Zoning Zoningofceuseonly <br /> Permit Application Shoreland Permit it:DCPSHL- I - 4 t? <br /> Application must he 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 /> Nam t ' L 1)(A I r t 6 Agent Name <br /> Address (/t �1 Agent Address <br /> 3228 2i dt wad <br /> City,State,Zip City,State,Zip <br /> I'}'ladis(m. ( 53704 <br /> Phone Agent Phone <br /> (CO5-7Ha ( Par�c,rC) <br /> E-Mail Agent E-mail <br /> YYl I ck-G Ii @ 5‘0(10,i( (}'1'x'1 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> fklj P ix,IA <br /> i. 5540 <br /> Parcel Number(s) Zoning District <br /> 0/0.7 — III -'1800 -2- <br /> CSM Lot Subdivision Block/Lot <br /> q I 2 <br /> Project Description <br /> S � <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? ❑ 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? 0 Yes ONO <br /> Have you contacted the Dane County Land and Water Resources Department about this project? 0 Yes❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> u 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 /> u All vegetative areas payable to Dane County Zoning. The fee for <br /> u Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> u 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 /> Applicant signature: Date: <br /> 11:Zoning\Shorcland-Wetland Zoning\Chapter 11 Forms\DCPSIIL_Application.docx Version 1.1 Created 12272013 <br />