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a DRIVEWAY CONST UCTION PERMIT APPLICATION TOWN OF BERRY—� `DANE COUNTY, WISCONSIN Applicant: Name: (�'�)� -'('.Y if L,J ( Vine I '---.0L' I ti 41 Dr..VQ itcyymt Current Mailing Address: lb(;_ 1i 1))y� W, City, State, ZIP: voo ' I 8 • Phone Number: ICU _,S2 _ ild Email: VY(S ;0�c de 1/e,lc.�p(}ti'1 f.C( •y� Specific Site Location/Nearby Roads: 0 • )(1 ' 1 J Parcel #:C -/O ff1— 22a-�3 0- • My signature J low indicates that: I have received a copy of the Driveway I rdinance and the Applications Guide, and that I have attached the information as reques ed for driveway permits in Section A(2) in the Driveway Permit section of the Applications Guide, and thai I agree to construct the driveway in acco dance with Town of Berry Driveway Permit Ordinance 301.1 and to follow the plans and other documents as ap.roved by the town board which become part of this permit, and that I have paid the application fee of$ 3*, T .(Pto the town Clerk/Treasurer, and that I hereby give permission to the Town Bo.rd and/or their representative which could be the Plan Commission or other inspector authorized by the t wn board to enter the property in order to evaluate the site of the proposed driveway and to verify compliance th and/or to enforce the Driveway Ordinance. Application Signature: ,,,,,,11171/ / ,t`f f, Date: 1 / 14 / IS— Board decision: Approve ✓ Deny Date 7 / 1 ? / )5' Culvert required in right-of-way Yes No ✓ Size Engineering Plan required? Yes No Additional Requirements? Yes if yes see attached requirements No Driveway construction must begin by Date 7 / I g / /6 Driveway Permit expiration Date 7 / I g / ) 7 Amount of cash bond required: $ n . Any cash bond required must be provided to the Town Clerk/Treasurer befor,the mit is iss ' Chair Signature: (� ��'_ .. ,,/ Date 7 / I If / i Permit issued by: Clerk Signature 1JJ 1a� 11:4- Date 7 / I s' / tS Permit is not valid unless signed by the Applicant,Town Chair and Town Clerk Final inspection approval by: Signature Date / / Cash Bond returned $ with interest$ Date / / Original Copy—Office Files Copy-Applicant