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La. Dane County Department of Public Works, Highway and Transportation <br /> ACCESS PERMIT <br /> This application and permit is required and shall be issued in accordance with the provisions of Section 83.027 of the <br /> Wisconsin Statutes and Chapter 79 of the Dane County Code of Ordinances. <br /> Applicant is to complete all of the following requested information(please Print or tvoe): <br /> ) Ann I/ County Trunk Highway to <br /> NameA which access is requested: (� <br /> 1-W - <br /> ddress <br /> city State 5j10 <br /> Zip <br /> 60i - I - - 7s 602' ? May144.( i< 5752 <br /> Home Phone ' Work Phone FAX E-Mail Address <br /> Existing Access?: If yes,how modified? (check one): ® � �� <br /> ZI Yes ❑No ❑.Relocated ❑ Removed E Change of use <br /> S Culvert replace El Asphalt Paving <br /> Describe use Mtti 1-T.1- F cV.:: Cs H4 i=f./ 4CC 66S W+T H. 9181, 9 t 7s or H K P <br /> J. . <br /> 'Location(check one): Town ❑Village ❑ City of P / <br /> L2.L7SS l .�/�l�:S k� <br /> Section <br /> Name of Highway and North/South/Eas 421.ide: G (� P <br /> Name of nearest cross road: U t o 11 4 L L E\( <br /> Distance and direction from nearest cross road: <br /> Existing Zoning: Zoning meets intended use?: <br /> ❑ Yes ❑No <br /> T,.-Yp e of Permit Requested(refer to reverse side for explanation of controlled and non-controlled access): <br /> Li_J $110 Temporary Controlled Access ❑ $75 Temporary Non-Controlled Access <br /> ❑ $110 Agricultural Controlled Access $75.Agricultural Non-Controlled Access <br /> ❑ $110 Residential(single family)Controlled Access $75 Residential(single family)Non-Controlled Access <br /> ❑ $220 Residential,Joint Access> 1 parcel = $220 Commercial,<100 ADT** <br /> ❑ $1,100 Private/Public,New/Existing,Street or Road _ $550 Commercial,>100 and<1,000 ADT <br /> i$45 Miscellaneous $1,100 Commercial,.>1,000 ADT <br /> ADT denotes Average Daily Traffic. Data substantiating ADT for access or road intersoctiuris may be required. <br /> Check or money order in the amount of 45- ,payable to the Dane County Department of Public Works,Highway <br /> and Transportation is enclosed. Cash will only be accepted in person. Do not send cash in the mail. <br /> The applic ;t understands :e d ees that the permitted work shall comply with all permit provisions and conditions listed on <br /> the reverse de hereof, an spa,ial provisions listed below or attached hereto, and any and all plans,details or notes attached <br /> hereto and s :de a •- -.f. ;roe owner is responsible for notifying p rt3' p Eying Dane County of any conditions and/or restrictions. <br /> By �� <br /> Signa of Applicant/Repres s tative <br /> Date 5*-- <br /> ( � Q <br /> N.OTE:. App cation should be accompanied with plans or plat or CSM when appropriate. Application fee must accompany <br /> all applications. Applications to be submitted to Dane County Department of Public Works, Highway and Transportation, <br /> 2302 Fish Hatchery Road, Madison, WI 53713. Contact the Assistant Commissioner at 266-4036 or Engineering office.at <br /> 2664037 with any questions. Any applicants which are denied a permit may appeal the decision to the Dane County Public <br /> Works and Transportation Committee, <br /> DO NOT WRITE OR TYPE BELOW THIS LINE--FOR DANE COUNTY USE ONLY <br /> PERMIT APPROVAL BY DANE COUNTY COUNTY PERMIT NUMBER; O ,4-007 <br /> The foregoing application is hereby approved and permit issued by.Dane County subject to full compliance by the Applicant <br /> with all provisions and conditions stated herein and on the reverse side hereof and all attachments.hereto, <br /> Other Special Provisions: <br /> B 4 <br /> By �7.��_ ,�. -08 <br /> Signature of Dane County Representative Date <br /> By - — -'r 266 4TH /4 <br /> Title . <br /> Phone <br /> 2nn007,7:53 AM Page 1 of 2 <br /> r:Nthared forms\pe ultslacceas-2007,Aoc <br />