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a� <br /> COMMUNICATION TOWER INFORMATION FORM(CTIF) <br /> CONTACTS <br /> Property Owner's Name Don Squire, Jr. <br /> Property Owner's 2046 Norgaren Rd Stoughton WI 53559 <br /> Mailing Address Street City State ZIP <br /> Property Owner's Phone Number ( 6 0 8 ) 8 7 3-4 6 6 3 <br /> Agent's Name&Affiliation Nathan Ward, Buell Consulting <br /> Agent's Relationship to Property Owner Agent <br /> Agent's Relationship to the Proposed Tower (e.g. wireless <br /> service provider,site acquisition firm,tower builder,etc.) Site Acquisition Specialist <br /> Agent's Mailing Address 1200 Riva Ridge Racine WI 53402 <br /> Street City State ZIP <br /> Agent's Phone Number ( 414 ) 7 8 8-13 2 7 <br /> PROPOSED ACTION <br /> Current Zoning Al CUP Acres .3 6 <br /> Proposed Zoning(only if rezoning) Rezone Acres(if applicable) <br /> Have the property owner and the agent/tower sponsor formally completed a binding Yes No <br /> letter of intent, option to lease, or lease? Please attach a letter from the property <br /> owner(s)consenting to the application. Circle One <br /> Yes No <br /> If applicable,does the lease area coincide with the proposed CUP area? <br /> Circle One <br /> LOCATION <br /> Town Dunkirk <br /> PLSS location(Township,Range, '/4'/4 Section) 0 2/0 5/11 <br /> ParcelNumber(s) 026/0511-023-9001-1 <br /> NE Corner Hwy. 51 & Pleasant Hill <br /> Street Address(or Proximity to Nearest Address) <br /> Road <br /> Coordinates in Decimal Degrees <br /> (00.000000 Lat.,-00.000000 Long.) 42 . 920367 L a t, -89 . 168994 Long <br /> Is the subject property located in the Height Limitation Zoning Overlay District (HLZO), Yes No <br /> roughly within three miles of the Dane County Regional Airport(check with Zoning staff)? Circle One <br /> H:\Zoning\Zoning Division Documentation\Informational Materials\Communication Towers\Communication Tower Application <br /> Packet 09-2010.doc <br /> Page 6 of 10 <br /> 210 Martin Luther King Jr.Blvd.•:Room 116,City-County Bldg.4'Madison,WI 53703-3342•2 Phone:608.266.4266 •Fax:608.267.1540 <br />