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X61 -4 <br /> • DRIVEWAY CONSTRUCTION PERMIT' AI'PL.ICATION f <br /> TOWN OF BERRY—DANE COUNTY, WISCONSIN <br /> Applicant: Name: •t a.61(.. 4 �c- °►`ICIAc. <br /> 0 <br /> Current Mailing Address: i - <br /> City, State. ZIP:.._)j..C.C.iC..- L._ J-11-1 1 l.-�_ I ` — j, <br /> Number: i Email: ��, 1 �C't i _t. 5. e.d ' <br /> Phone Number: --1���" 37 - ` _. <br /> Specific Site Location /Nearby Roads: _ t <br /> Parcel 4: C:011-- b2 b r- ;:50:24. -- a. hi <br /> My signature below indicates that: <br /> I have received a copy of the Driveway Ordinance and the Applications Guide, and that <br /> I have attached the information as requested for driveway permits in Section A(2) in the Driveway <br /> Permit section of the Applications Guide, and that t <br /> I agree to construct the driveway in accordance with Town of Berry Driveway Permit Ordinance 301.1 <br /> and to follow the plans and other documents as approved by the town board which become part of this permit, <br /> and that , <br /> r-F to the town Clerkfrreasurer. and that <br /> I have paid the application fee of$ 'a�>:;,. <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 to board to enter the property in order to evaluate the site of <br /> the proposed driveway and to verify compliance with and/or to enforce the Driveway Ordinance. <br /> ,,,.Application Signature.Opt. !;it.,f ti � <br /> Date:, /12-, /- , <br /> _ _ _.._ <br /> Board decision: Approve J Deny Date x._...._/ 1 / 1 <br /> Culvert required in right-of-way Yes No Size___ <br /> Engineering Plan required? Yes No / <br /> • <br /> Additional Requirements? Yes if yes see attached requirements No ✓ <br /> i <br /> Driveway construction must begin by Date ? / i 1 / I ko <br /> Driveway Permit expiration Date /___...1 7 i <br /> Amount of cash bo required: $ Any cash bond required must be provided to the Town <br /> C lerk/Treasurer hefo ;the •e• it is issue'. <br /> / / <br /> Chair Signature: <br /> Date 64, / 1 7 / ev l <br /> 1 Date l 17 / /S — 3 <br /> Permit issued by: lerk Signature !11 !j <br /> Permit is not valid nless signed by the Applicant,Town Chair and Town Clerk 3 <br /> Final inspection approval by: Signature <br /> Date /— / <br /> Cash Bond returned $ with interest $ Date / /_._ <br /> ii <br /> Original Copy–Office Files Copy-Applicant --- 1 <br /> 3 <br /> 1 <br /> a <br /> X 1 <br />