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Dane County Department of Public Works, Highway and Transportation vs <br /> g '' APPLICATION FOR <br /> 0 ACCESS PERMIT <br /> This permit is required and shall be issued in accordance with the provisions of Section 83.027 of the Wisconsin Statutes and Chapter 79 of the Dane <br /> County Code of Ordinances. <br /> APPLICANT INFORMATION <br /> Name <br /> I. <br /> E-Mail Address <br /> Street Address 2 C City State a-C- 0.2 p y 1•C 041 <br /> /v?/f /2 v ► ', 'J.-N._ <br /> Zip <br /> Home Phone .,i 6,-JZ �,�57c>'— <br /> Work Phone <br /> Y3S— 35 '5-6-07 Fax Number <br /> PROPOSED ACCESS LOCATION <br /> County Trunk Highway in which access is requested: Controlled Access? 4 Town U City 0 Village of: Section <br /> Numf <br /> ❑ Yes fig, No 0 N..t1..rye <br /> Existing Access? If yes,how modified? .� <br /> fa. Yes ❑ No 0 Relocated 0 Removed 2 Change of Use 0 Culvert Replace Ej Asphalt Paving <br /> ascribe Use: //�^ XI J J �^ ---- -- `.,,c-1-. <br /> C <.,D e 4 . ---4- ! , c) / 1 c S' 4 cs1�, 6,,'// S •�/ C..).5 Gt.) X ��-��[ F, A a.r/?" cl (s c) <br /> Which Side of County Trunk Highway? Nearest Cross Road //��/ <br /> Ell <br /> North El South El East 2, West ..5-c.,,-1 t/n/l? C//4 • <br /> Distance and Direction of Nearest Cross Road / Existing Zoning: Zoning Meets Intended Use? <br /> ( 2 /7'-r (..e ,e2-64t- J o L-- .. • / ja Yes Ej No <br /> PERMIT FEE :` <br /> Type of Permit Requested: <br /> 1 $110 Temporary Controlled Access I I $75 Temporary Non-Controlled Access <br /> U $110 Agricultural Controlled Access LI $75 Agricultural Non-Controlled Access <br /> N $110 Residential(single family)Controlled Access 0 $75 Residential(single family) Non-Controlled Access <br /> al $220 Residential,Joint Access> 1 parcel [ J $220 Commercial, <100 ADT" <br /> [ $1,100 Private/Public, New/Existing, Street or Road El $550 Commercial, >100 and<1,000 ADT <br /> 0 $45 Miscellaneous El $1,100 Commercial,>1,000 ADT <br /> "ADT denotes Average Daily Traffic. Data substantiating ADT for access or road intersections may be required. <br /> Permit fee made payable to Qane County I lghwa�Department must accompany all applications. <br /> A/12 L-.G v.v <br /> PERMIT CONDITIONS&SIGNATURE___ <br /> Applicant acknowledges that (s)he has read and understand the requirements for obtaining an Access permit. By signing this <br /> application, applicant agrees that Dane County may establish additional provisions prior to application approval. Applicants shall <br /> receive notification of any special provisions. <br /> Applicant further understands and agrees that the permitted work shall comply with all permit provisions and conditions listed on the <br /> reverse side hereof,any special provisions, and any and all plans, details or notes attached hereto and made a part hereof. Property <br /> owner is responsible for notifying Dane County of any conditions and/or restrictions. <br /> By 3 ,_ S / .. <br /> Signatu..of p ' ant/Representative Date <br /> 6✓41- ,4C--Q., o C- _ A4. c7 7..21/ <br /> Print Name and Title Phone <br /> NOTE: Application should be accompanied by plans or plat or CSM when appropriate. Submit application to Dane County <br /> Department of Public Works, Highway and Transportation, 2302 Fish Hatchery Rd, Madison, Wi 53713. Contact the Engineering <br /> Office at(608) 266-4037 with any questions. Anv applicants which are denied a permit may appeal the decision to the Dane County <br /> Public Works and Transportation Committee. <br /> Pane 1 of 2 <br />