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DRIVEWAY CONSTRUCTION PERMIT APPLICATION d b i -ii <br /> TOWN OF BERRY-DANE COUNTY,WISCONSIN <br /> Applicant: Name: vA R_`{ 1- 2-E---,„) 1lJ CS OA) <br /> Current Mailing Address: ;.„ L EL D - <br /> City. State;ZIP: 13 L -c_i _ f;7 ct -TNT t ) i S3S7S <br /> Phone Number: e708/16,7-3 7 01_ Email: Tr;, E S• (4.)/n a- <br /> Specific Site Location/Nearby Roads: c,k�se u� q)cy'Ka i/, co/ <br /> Parcel#: O FO Y 2 V1Ov Oti:a 13 Z y&/Io L <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 /> I have paid the application fee of$ . OtC to the town Clerk/Treasurer;and that <br /> I hereby give permission to the Town Board an 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 yeti co op 'ante with and/or to enforce the Driveway Ordinance. <br /> ,/ c a <br /> Application Signature: t, Date: 7' / 0 $ / /,6 <br /> Board decision: Approve ✓ Deny Date 9 / 19 / / 1, <br /> Culvert required in right-of-way Yes ✓ No Size ►I x 4 <br /> Engineering Plan required? Yes No <br /> Additional Requirements? Yes if yes see attached requirements No <br /> Driveway construction must begin by Date 9 / / 9 / 17 <br /> Driveway Permit expiration Date 9 / 19 / / r <br /> Amount of cash bond required: $ . Any cash bond required must be provided to the Town <br /> Clerk/Treasurer befo the rmit is i uejr <br /> Chair Signature: L Date °, / `I / (G <br /> Permit issued by: Clerk Signature- Kate Date CI / 19 / / <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 />