Laserfiche WebLink
a 6 6 7 - )3 <br /> DRIVEWAY CONSTRUCTION PERMIT APPLICATION <br /> TOWN O BERRY-DANE COUNTY, WISCONSIN <br /> Applicant: Name:, di -/, 1d2-itL/,n QM-0 <br /> Current Mailing Address: /1/ E. 1 V filth ok,. <br /> City, State, ZIP: /Oa erg Mal,/le € W t ��. 0 <br /> Phone Number:(6g-576- 115679 Email: <br /> Specific Site Location/Nearby Roads: 75re.,OG��,' <br /> Parcel#: OA -O s a'7--�t3(-el - ?co A - OJ <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 <br /> #2003-1 and to follow the plans and other documents as approved by the town board which become part of this <br /> permit, and that A- <br /> I have paid the application fee of$ 3�0, t)- 1 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: Date: 9 / /5/ / G <br /> Board decision: Approve I Deny Date 11 / 0 9 / b7 <br /> Culvert required in right-of-way Yes No Size I g n X 30 <br /> Engineering Plan required? Yes No 1 <br /> Additional Requirements? Yes if yes see attached requirements No <br /> Driveway construction must begin by Date 1 1 / 19 / a o % <br /> Driveway Permit expiration Date II / l i / 'a•6c) <br /> Amount of cash bond re• ired: $ . Any cash bond required must be provided to the Town <br /> Clerk/Treasurer be ire ermit is i. sued. <br /> Chair Signature: 'k_ a.,a, Date A t / l'\ / LnO1 <br /> Permit issued by: Jerk Signature 1_AM _ I/ • 0 Date <br /> b / cU / 63 <br /> Permit is not va d 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 />