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DocuSign Envelope ID:E9168411-098D-431C-9CD3-E508EC3A33D1 - T 0 )2, `0 5- ?O2 <br /> 7555 W. Old Sauk Road <br /> Driveway/Culvert Permit Verona,WI 53593-9700 <br /> Phone: 608-833-5887 <br /> Town of Middleton Fax: 608-833-8996 <br /> Last Updated:02/27/2020 info@town.middleton. <br /> wi.us <br /> Part A: (To be Completed by Applicant and submitted to Town) <br /> Builder's Name:Premier Builders, Inc. <br /> Builder's Address: 102 N Holiday Drive Waunakee WI 53597 <br /> Builder's Phone:608-849-6770 Builder's Email:Jeanette@premierbuildersinc.com <br /> ,—DocuSlgned by: <br /> —DocuSlgned by: <br /> *Property Owner's SignaiuP 't wl.ww u °��� 5/27//2021/ 5/27/2021 <br /> `—77FCE7BDDE97487... �9B1 D15D784CF4A7... <br /> Property Owner's Name: Matthew Becker & Maria Signore Becker <br /> Property Owner's Address: 17 Pilgrim Circle Madison WI 53711 <br /> Property Owner's Phone:616-307-2569 Property Owner's Email:signore.maria@gmail.com <br /> Lot or Parcel Description: Street Address <br /> Lot Number 2 <br /> Plat Name or CSM Number CSM 14093 <br /> Proposed Driveway Location to Property:See Attached <br /> (use an attached sheet for required sketch or supply plot map) <br /> Drainage Considerations(include size of proposed culvert if known): <br /> Other Information: <br /> *I understand work completed without written authorization from the Town Board or their representatives is subject to removal <br /> and/or replacement at the Owner's expense. I agree that all work shall be in compliance with Chapter 8.01,of the Town's <br /> Ordinances at the time of installation and with the notes listed on the opposite side of this form. I agree to inform any sub- <br /> contractors involved with the installation of the driveway and/or culvert of this information and the notes listed. <br /> X �- 05 /25 / 2021 <br /> Buil is Signature Date <br /> (Over) <br /> 1 <br />