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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Optunities, LLC ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 4444 State Rd 139,Oregon,WI 53575 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)575-6668 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Nathan Ward, Buell Consulting Minnesota Towers ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1200 Riva Ridge 323 S. Hale Street,Suite 103 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Racine,WI 53402 Wheaton, IL 60187 <br /> PHONE PHONE ❑Site Plan approval from <br /> (414) 788-1327 (847) 226-5532 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> nward @buellconsulting.com yurid @centralstatestower.com ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) [] Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> 0 PARCEL 251/0810-301-0203-2 PD 7.10 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 30 1,4. NE 1/41/4. SW ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 2290 Darwin Road <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> 12,769 1 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Communications monopole and compound with associated equipment cabinets,shelters etc. Q Zoning District <br /> . FA This project is a new building or structure. 0 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0,Rural Address <br /> FIEWER rEPTIC (new/existing). <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 104.3 ❑ Wetland/Floodplainf <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ ErOStonControl permit <br /> ` TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: :fllltng/acpess) <br /> 4,225.0 p Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options, <br /> (Please round to nearest dollar) ♦ -► -► ♦ ♦ -' $ 125,000.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes INNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? plies ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Elves igNo ❑Don't know <br /> 7. Is this to correct a violation? Elves MIN <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —+ —► <br /> 545-112(4/08) <br />