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DRIVEWAY CONSTRUCTION PERMIT APPLICATION a 66 Ql - <br /> TOWN OF BERRY-DANE COUNTY, WISCONSIN <br /> Applicant: Name: Q&Ar t dJ -4- /Y4 n c y /t�• K6rl <br /> Current Mailing Address: G� y/4 r /9? Vat jl e y 2 d <br /> City, State,ZIP: A442-0 /yl /7/e_ WI S35-6 0 <br /> Phone Number: 60 79e 50 6 Email: <br /> Specific Site Location/Nearby Roads: Fa,- li r.e to Ai <br /> Parcel #: (A167 - 172- - 99ooa -3 <br /> My signature below indicates that: <br /> I have received a copy of the Driveway Ordinance, the Applications Guide and Independent <br /> Inspection's building 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 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 11 '' <br /> I have paid the application fee of$ 3 � 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 with and/or to enforce the Driveway Ordinance. <br /> Application Signature: ,ia I�.t <br /> t� -- Date: .5' l !2- l Oq <br /> Board decision: Approve Deny Date (p / I / 200c1 <br /> Culvert required in right-of--way Yes X No Size e- `iL <br /> Engineering Plan required? Yes No Q <br /> Additional Requirements? Yes X if yes see attached requirements No %.0 LF <br /> �,r kovs e-- <br /> Driveway construction must begin by Date G l I S l a O 1 0 <br /> Driveway Permit expiration Date (p / / 5— / 2 !f <br /> Amount of cash bon. required: $ . Any cash bond required must be provided to the Town <br /> Clerk/Treasurer befor: the .- is iss ed. <br /> Chair Signature: Date .G / I''S / z.ffioci <br /> Permit issued by: Clerk Signature •/,! Date 7 / /p / pb <br /> Permit is not valid unless signed by 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 />