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X063 - i b <br /> DRIVEWAY CONSTRUCTION PERMIT APPLICATION <br /> TOWN OF BERRY-DANE COUNTY;WISCONSIN <br /> Applicant: Name: {-1- i--te 6 // /A/ <br /> Current Mailing Address: 93 Ill 6'- ,>7 J (1&77, �!,-/ <br /> City, State, ZIP: h7,r,3,, ,.,,, r,,, ,.� G■ ,; 3 c jam, <br /> Phone Number: 7 e R _ 3 76 G email ,2 'A-aii / e e/>a rte,s , .i,f <br /> Site Location: Address/location of site: ?3 3 g e ;-,„ //p dry pc, �: Ijleki ;,., C±114 <br /> My signature below indicates that : �I <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 with Town of Berry Driveway Permit <br /> Ordinance#2001-1 and to follow the plans and other documents as approved by the town board which <br /> become part of this permit, and that <br /> I have paid the application fee of$ 3 v o "`J 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 enter the property in order to <br /> evaluate the site of the proposed driveway and to verify compliance with and/or to enforce the <br /> Driveway Ordinance. <br /> Applicant Signature: _ � � � / ---(� Date / 1/3 / o 3 <br /> Board decision: Approve I Deny Date ..2 / / 7 1 C <br /> Culvert required in right-of-way Yes No / Size <br /> Engineering plan required? Yes No I <br /> Additional requirements Yes if yes see attached requirements -__ No 7 <br /> Permit is taken out under Driveway Ordinance # C )t - <br /> Driveway construction must begin by Date / 7/±d. <br /> Driveway Permit expiration Date / 7/_5 <br /> Amount of cash bond required: $ . Any cash bond required must be provided to the Tom' <br /> Clerk/Treasurer before th nit is issued. <br /> Chairman Signature: `%oc 1a.,A_. Date P / /r'/ 03 <br /> Permit issued by: Clerk Signature 1Pr)rdc_____MEL___ Date _/ a 1 0.3 <br /> Permit is not valid unless signed by the Applicant,Town Chairman,and Town Clerk <br /> Final inspection approval by: Signature: idep,t, ,Z ga,,,,��y Date y/ Z.Z-/ 6 <br /> Cash Bond returned: $ with interest$ Date: / <br /> Check number <br /> Original Copy—Clerk/Office Files Copy—Applicant <br />