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07011. - 7 <br /> DRIVEWAY CONSTRI:CTION PERMIT APPLICATION <br /> TOWN OF BERRY -• DANE COUNTY, WISCONSIN <br /> Applicant: Name:grigii2p_G141431_ <br /> _ <br /> Current Mailing Address: 225 IV /41.161.8 ,i ,51-. <br /> , - <br /> City. State. LIP: ...)t-,7 4.9 1 1 Tul i,(. 2.- 6 3.S&/ <br /> Phone Number: 674S7_554; - 7/ ,7 . E mail:_ (14/... ..:tili,liaiinti6Cia,.C.C/11 <br /> i 2 --. * <br /> Specific Site I.ocation I Nearby Roads: _ LC I-.4 it I ii''j(CL: Lc(,c i _ <br /> Parcel ti; O0.7- i 7 1 - 9D7 - I <br /> My signature below indicates that: <br /> I have received a cop) of the Drkeway Ordinance and the Applications Guide,and that <br /> 1 have attached the information as requested for driveway permits in Section A(2) in the Driveway <br /> Permit section of the Applications tinkle, and that <br /> I agree to construct the driveway in accordance with I own 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 s 3c,-. g, ._ to the town Clerkffreasurer.and that <br /> I hereby give permission to the'I ov,n Board and,or their representative which could he 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 /> :•- <br /> Application Signature: ------7.. <br /> Z---- <br /> . - Date: e.' / <br /> _ ...._ <br /> Board decision: Approve / Deny Date 1 6 i 11 /_ pg. <br /> ..._ <br /> Culvert required in right-of-way Yes / No el <br /> • . <br /> Simpf,calcneee,ny o-&.. <br /> . . <br /> Engineering Plan required? VeN / NO <br /> .-. <br /> Additional Requirements? Yes it)es see attached requirements No Z <br /> - ---- <br /> - <br /> Driveway construction must begin by Date l D I 1 / 1 1 <br /> ..._ <br /> Driveway Permit expiration Date _ Ip 1 I 7 / A r _ <br /> Amount of cash h d require : $ . Any cash bond required must be provided to the Town <br /> Clerk/Treasurer bd.° tit is issue . <br /> Chair Signature: \-- 6 <br /> '... . .., Date 1 0 <br /> __.._ _ 17 I 6 <br /> Permit issued by:Clerk Signature 1324"044,...M Date i 0 . 17 1(0 <br /> Permit is not valid unless signed bv the Applicant.Town Chair anti Town Clerk <br /> Final inspection approval by: Signature Date / .........• ____....... <br /> _ . _._.... <br /> , <br /> Cash Bond returned$ __. with interest $ [)ate <br /> i <br /> Original Copy-Office Files cop's - Applicant <br />