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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$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 ! �h jj Age Name <br /> I���/� �(�1u✓ V 1311 k; -K LaST yt 1'2 A/c- <br /> Address Agent Address �V <br /> 6 ,I2 wood De eiL o <br /> City,State,Zip City,State,Zip <br /> kC5 cry 53s'esr4ok C' ` Lc� cSPO) <br /> Phone Agent Phone <br /> C--e*-- X /3 - 3 o32 (,e)q- 35.3 <br /> E-Mail Agent E-mail <br /> Cilcfn�_�,) pLC ,Lcyr»') <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address <br /> I Town/Section Acreage <br /> 22/ -'_J 6 `1a�tl�ccI d//�� <br /> Parcel Number(s) tJ Zoning District <br /> C7 5-0/0q.0 I`63 — 7Joo f.- <br /> CSM Lot Subdivision Block/Lot <br /> /0 1541- <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 A Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes EINo Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? cyrNo 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 /> o Any proposed structures Please have cash or check payment available <br /> ❑ All impervious surfaces at time of application submittal. Checks are <br /> o All vegetative areas payable to Dane County Zoning. The fee for <br /> o 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 did property. <br /> Applicant signature: Date: 6 - /o - 1 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version Ll Created 12272013 <br />