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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit li:DCPSHL- <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Pennit fee is 5150 <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 /> Names er Agent Name <br /> „keys/34 .�,ize'-j <br /> Addressc3 ��9Rzi <br /> Agent Address <br /> 3 2 <br /> City.State,Zip City,State,Zip <br /> Phone_ozeide-Je,), a ,s-37/8 <br /> ne . Agent Phone <br /> j� <br /> C Y gX9 <br /> E-Mail �l Agent E-mail <br /> -31:4/0/7e tom',6,e4n,64c47,6177' <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> e S <br /> Property <br /> "A�ddre� �� Town!Secti �f_ v. Acreage <br /> Parcel Number(s) Zoning District <br /> 0,(?i0 —.Q.341-' 9sva j- y, <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> /u X12 C (Yaii ^yi 0-h., �'�2fyrrr<' <br /> it <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? El Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑Yesco El Don't Know <br /> Is this project associated with a recent rezone/CUP/variance:Pk/No If yes, petition/appeal# . <br /> is this permit to correct a violation'? ❑ Yeslo <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 /> a Property lines with dimensions <br /> ❑ All existing structures Permit Fee due at time of application <br /> a Any proposed structures Please have cash or check payment available <br /> All impervious surfaces at time of application submittal. Checks are <br /> a❑ All vegetative areas payable to Dane County Zoning. The fee for <br /> a 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 applicatio• for a shoreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property owne . - duly • orized representative,and niay sign this permit application on the <br /> behalf of the owner(s)of said pr.:- . . <br /> Applicant signatur> --- Date: <br /> H:\74ninv.Shrntelnnd-WPtlnnd 7nninv'Chantrr 11 Rrnm`.DCPRH1. Annlicatinn.dcxcx Verxinn 1.1 Creafad 1)).722(111 <br />