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r • I <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Town of Rutl`ind ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 4177 Old Stage Rd Brooklyn, ,JI 53521 Variance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> 608-4 - 2 84 - 880 d_e oil '@a• •II ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Tom Reece , SAC direless ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 8426 Elderberry Rd <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Madison, `WJI 53717 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 608-698-8968 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> treece@sacw.com ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> 4 PARCEL frontage drawn to scale. <br /> NUMBER 0 0 0— —• 0 —0 ! — 18. <br /> TOWNSHIP: SECTION: <br /> Rutland NE '/4: SE '/4'/<: LI Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 4232 Ct.r Hwy A LI Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Proposed cell tower -Ind 50 sq ft com7-ound LI Zoning District <br /> . ®This project is a new building or structure. ❑ Permitted Use? <br /> LI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> na ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> twr 180' bldg 10' 1 <br /> La <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 345 + TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 345 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -1. -1. ♦ -10, - 18 9 000 and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from,a pond or lake? ❑Yes allo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 'L7 Yes I2g No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes IS 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):�U.C.V.t y ,¢.7..r1 G/f..49 ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 21No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -I ♦ -► <br /> 545-112(4ros> <br />