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Dane County Shoreland Zoning Zo„i„geiceuse 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 Agent Name <br /> Amber & Ryan Huemmer Premier Builders, Jeanette Acker <br /> Address Agent Address <br /> 904 Lindsay Court 102 North Holiday Drive <br /> City,State,Zip Cottage Grove, WI 53527 city,State,Zip Waunakee, WI 53597 <br /> Phone Agent Phone <br /> 608-279-5424 (608) 849-6770 <br /> E-Mail Agent E-mail <br /> amber@thhtrealty.com; ryan@thhtrealty.com jeanette@premierbuildersinc.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 07 '' SE %% Sw 30.56 <br /> Parcel Number(s) Zoning District <br /> 0711-074-9125-0 <br /> CSM 15434 I Lot 1 Subdivision I Block/Lot <br /> Project Description <br /> Construct a 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? IR Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? BNo If yes, petition/appeal# . <br /> Is this permit to correct a violation? 0 Yes No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? 0 if es ❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> o Property lines with dimensions <br /> o All existing structures Permit Fee due at time of application <br /> o Any proposed structures Please have cash or check payment available <br /> o 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 /> o 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)o 1: .roperty. <br /> Applicant signature:' 4y ., ...c ; Date: 6 _ fL <br /> I H:\Zonin \Shor 3 <br /> g eland Wetland Zoning\Chapter I I Forms Version 1.1 Created 1227201 <br /> i <br />