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DRIVEWAY CONSTRUCTION PERMIT APPLICATION (2b VI" el <br /> TOWN OF BERRY—DANE COUNTY,WISCONSIN <br /> Applicant: Name: i\lt A 11 K E W 4— j Pt E r-- 0 <br /> Current Mailing Address: P 0 0 <br /> City, State,ZIP:U3--/-13?—C,�0 J 5 P L P 1 N S v 1 5353\2 <br /> Phone Number_ (Q 3 55 Fmutil: Mte.r 2,3(-1 d, \ c1ckoc) co ■ <br /> Specific Site Location I Nearby Roads: Vi <br /> Parcel#: 0 0 — . 0 0% — <br /> My signature,•-ow indicates that: - <br /> I hav.�rued a copy of the Driveway Ordinance,the Applications Guide and Independent <br /> Inspection's a' ding packet,and that <br /> I have attached the information as requested for driveway permits in 2a to 2h in the Driveway Permit <br /> section of the a a lications Guide, and that <br /> I -. to construct uct the driveway in accordance with Town of Berry Driveway Permit Ordinance <br /> #2003-1 and la, follow the plans and other documents as . +ved by the town board which become part of this <br /> permit, and la ;1 �. <br /> I have -■ the application fee of$ 300. 00 to the town-Clerk/Treasurer, and that - <br /> I hereby give permission to the Town Board and/or their representative which could be the Plan <br /> Commission or other inspector authorized by the town board to enter the property in order to evaluate the site of <br /> the proposed driveway and to verify compliance and/or to enfince the Driveway Ordinance. <br /> Application Signaturc �i •r2v• i :�i�A,„a Date: /c / 0�3 I /'7 <br /> act AC) C. V MCA U() n <br /> Board decision: Approve )(.., Deny Date 1 / .1 15— <br /> Culvert rapine' in right-of-way Yes No X Size <br /> Engineering Plan required? Yes No _ <br /> awl% 4.5, c P 4s� ��- o. s o, e„-• <br /> Additional Requirements? Yes h, if yes see anacbed requirements No <br /> Driveway construction most begin by Date I / a c7 / / 6. <br /> Driveway Permit expiration Date ) / 7-0 / 1 <br /> Amon nt of cash +a a required:$ " Any cash bond required mast be provided to tie Town <br /> Clerlareasmor r ti •7tiie i i i is Isar <br /> Chair Ste: ,•- .4 _ Date 1 / O <br /> Permit issued by: * Stgamnre / • Kul k Date / 1 a 3 / vs- <br /> Permit is not valid ,.. signed by the Applicant,Town Chair and Town Cleric <br /> Fns mad approval by: Signature - Date / 1 <br /> Cash Band returned S with interest S Date 1 / <br /> Original Copy—Office Fdes Copy-Applicant <br />