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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> American Telephone & Telegraph Co. <br /> 0 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 122 W Main Street,Madison,WI 53703 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ariel Stouder-SAC Wireless TBD ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 540 W Madison, 17th Floor TBD <br /> (City,State,Zip) (City,state,Zip) ❑Setbacks <br /> Chicago,IL 60661 TBD <br /> PHONE PHONE ❑Site Plan approval from <br /> (312) 971-7588 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ariel.stouder @sacw.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 /> ❑PARCEL 061125284403 A-1(EX) frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Pleasant Springs 25 1A. NE %1/4. NW ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 1717 County Highway B <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> AT&T is proposing to collocate on an existing tower and construct a new equipment shelter on existing concrete pad ❑ Zoning District <br /> . OThis project is a new building or structure. ❑ Permitted Use? <br /> r This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER rEPTIC (new/existing) <br /> HEIGHT IN FEET: i (r c/r NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <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: 1 ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: e 38 Pr filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ and available options. <br /> -+(Please round to nearest dollar) $ 85,000.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes Olo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ElKlo <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) ❑Yes �'4o ['Don't know <br /> 7. Is this to correct a violation? [Yes ✓INo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ♦ -► <br /> 545-112(4/08) <br />