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;603 -1/ <br /> • <br /> DRIVEWAY CONSTRUCTION(PERRIT APPLICATION <br /> TOWN OF RF.RRY-D_ . <br /> � J rN- ,WISCONSIN <br /> Applicant: Name: D r,,3,T <br /> Current Mailing Address: a. 3 OA G ECX 1 AL- <br /> City, State, ZIP: AD 1,s o/,1 �, S 3 7 / <br /> Phone Number:(,0 S_ al-7 -Q� email � wise . �v <br /> Site Location: Address/location of site: t- e L.L Pn )4 r R b . <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 <br /> Permit section of the Applications Guide, and that _ <br /> I agree to construct the driveway in accordance ments as approved by the town board which <br /> Ordinance #2001-1 and to follow the plans and other documents <br /> become part of this permit, and that <br /> I have paid the application fee of$ .306, u:' to the town Clerk/Treasurer, and that <br /> I hereby give permission to the Town board and/or their representative which could be the <br /> Plan Commission or other inspector authorized by the town board to <br /> with enter the property erty enforce in order to <br /> evaluate the site of the proposed driveway to verify compliance <br /> Ordinance. Date o / / 3 <br /> Applicant Signature: 1 a ✓�' <br /> decision: Approve ✓ Deny Date I9 / U <br /> Board / <br /> Yes d No Size a X 3 01 rut n;m;,c rn <br /> Culvert required in right-of-way <br /> lan required? Yes No <br /> Engineering plan / <br /> if es see attached requirements <br /> No / <br /> Additional requirements Yes Y <br /> Permit is taken out under Driveway Ordinance # 06,3._ <br /> Driveway construction must begin by Date 5 1_11 <br /> Driveway Permit expiration Date `; ! 9 / 5j <br /> Amount of cash bond required: S . Any cash bond required must be provided to the Town <br /> Clerk/Treasurer before th dt unit is issued. <br /> Date Z-J / 0 3• <br /> Chairman Signature: — _).. .<- - / / C�/ <br /> . <br /> Permit issued by: Clerk Signature . e_n C Date 1�Applicant,Town Chairman,and Town Clerk <br /> Permit is not vali d unless signed by the App _ <br /> Final inspection approval by: Signature: _—.---_- _-- -- <br /> Date — / .----'•---- <br /> Cash Bond returned: $ —.— <br /> with interest $ Date: <br /> I ^M Check number <br /> C•on%•—a nnlicant <br />