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• OUTDOOR SIGN INSTALLATION APPLICATION AND PERMIT Mail Application to Regional Office Wisconsin Department of Transportation DT1680 6/2006 s.84.30 Wis.Stats. This Permit is Revocable. For Locations Adjacent to Interstate and Federal Aid Primary Highways and the National Highway System Applicant-Sign Owner Area Code-Telephone Number 4d/benS g/doe,- / /l. Address,City,State,ZIP Code /0c2 -.7 ,614 le41,". i 5`37/3 E-Mail Address x l 5�4�F�p�✓SF:iP/�dRvKS'QC� ��oe:^ .Cep+-, (Pe it Applicant Signature) (Date) An agreement/lease with the landowner that allows installation of the described sign and continued access to the sign site must be obtained prior to approval of this application for all categories except on-premise. Nothing herein requires a property owner to have or to retain a sign on their land. Landowner Name —Print Area Code—Telephone Number ,GM. x.NL. ,G,c G Gob-836-51125r Address,City,State ZIP Code V2fZ 74,/;1 /4L/cd 4 A /'?e46Wekwr, -wc s3 TG i By my signature,I acknowledge that I am aware of the Permit Conditions and Restrictions listed herein and I affirm there are no easements or restrictions that would prohibit this sign from being erected. x ,/d161frAv4 7 c/i f (Landowner Signature) (Date) Installer Name License Number �O1iM$ al de& s/•9- /0? Address,City,State ZIP Code /G) � . i3 #d in 41 it lob o.4v, GJ/ 537/3 Highway/s / County l'‘ (i,Town IQ City ❑ Village Highway Side / EJ/¢/✓� O e 104/ ❑N 54S ❑ E ❑W Land Zoning(Supply proof) Date of Zoning Sign to Face C ON ❑S ❑ E INW ON\S ❑ E\W Sign Location(Legal Description) % A/rV g.1/4 of the 5;A) 1/4 of Section Township North, Range g Q East ❑ West Distance from sign to the pavement centerline of the closest road that intersects with the highway along which the sign will be erected. 8So E45 i~ w,,ii //a l/e 01.1 (Feet) (East,West,North,South) (Identify road measured from) Distance from highway right of way to sign Sign Illumination Height Above Ground Level(HAGL) S ft. lye Steady Light ❑No Light ❑Changeable Message ft. Sign Category and Fee Sign Design ❑ On Premises Free Standing -$175 Type 1 (Choose one) Type 2(Choose one) ❑ On Premises On Building-$175 Single Face ❑ Side by Side ❑ Real Estate along Interstate-$175 0 Back-to Back ❑ Over Under ® Off Property-$175 ❑ "V"Type ❑ On Building ❑ Service Club Meeting Notice—No Fee ❑ Does Not Apply ❑ Religious Meeting Notice—No Fee ❑ Agricultural Test Plot-$175 ❑ Sign on officially designated school bus stop shelter; Affidavit from school officials required-$175 ❑ Directional as defined by sec.TRANS.201.05 Wis.Adm. Code If box is checked, provide signature to the right-$175 ❑ Official(City,Village,Town,County,or State official to be applicant) (Agent Signature for Directional Attraction or Official) If box is checked,provide signature to the right -No Fee Completed by Wisconsin Department of Transportation • Sign is on Wi5DOT Project No. (Approved for Director of Highway Operations) • Cancel existing permit as condition of issuing this permit?❑ No ❑Yes If the answer is"Yes",provide permit number and issue date R.P.Number Inventory Sort Inventory Direction of Travel Highway Side Sign Area(Plus border&trim) Highway Direction ❑ N ❑S ❑ E ❑W ❑ Left ❑ Right sq.ft. 660 ft.+from R/W Scenic Byway Check Number Trans.233 Setback Issue Date Permit Number ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No