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aof5 - I1 <br /> DRIVEWAY CONSTRUCTION PERMIT APPLICATION <br /> TOWN OF BERRY—DANE COUNTY, WISCONSIN <br /> , II <br /> Applicant: Name: 1,0 Mi 8 `. Shelly V(AVI D'a l=3 t 1 <br /> CulTent Mailing Address: I3Ic Ti vt Dr . <br /> City, State, ZIP: ( lUCk CA►'Yh, WI 5.3515 <br /> Phone Number: (tOsr- /12-'fl-17-1 Email: Sc.shift &14WF(u tint-cow <br /> Specific Site Location/Nearby Roads: H612-5 13ralGt"rGV Rol . <br /> Parcel #: <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 <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 /> 1 have paid the application fee of$ 300 to the town Clerk/Treasurer,and that <br /> I hereby give permission to the Town Boar and/or their representative which could he 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 with and/or to enforce the Driveway Ordinance. <br /> Application Signature: Cj� Date: It / 2 3 / 15 <br /> Board decision: Approve ✓ Deny Date I / i 5' / 16 <br /> Culvert required in right-of-way Yes No ✓ Size <br /> Engineering Plan required? Yes No r/ <br /> Additional Requirements? Yes if yes see attached requirements No / <br /> Driveway construction must begin by Date 1 / I `I' / 17 <br /> Driveway Permit expiration Date 1 / l 9 / I <br /> Amount of cash bo d re.uir'd: $ . Any cash bond required must be provided to the Tow!I <br /> Clerk/Treasurer befoh the p:,mit is i s red. <br /> Chair Signature: ' Date I / f / / (o <br /> Permit issued by: Clerk Signature gm __ . r / Date / / 0 / / L <br /> ______ Permit is not va d unless signed .y the Applicant,Town Chair and Town Clerk <br /> Final inspection approval by: Signature Date / / <br /> Cash Bond returned$ with interest$ Date / / <br /> Original Copy—Office Files Copy-Applicant <br />