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OUTDOOR SIGN INSTALLATION APPLICATION AND PERMIT Mail Application to Regional Office <br /> Wisconsin Department of Transportation <br /> DT1680 6/2006 s.84.30 Wis.Stats. This Permit is Revocable. <br /> For Locations Adjacent to Interstate and Federal Aid Primary Highways and the National Highway System <br /> Applicant-Sign Owner Area Code-Telephone Number <br /> 1 �C �is ��' , /VL. i C. t'� '� . t 2 - 22 - SZ_S <br /> Address,City,State,ZIP Code Cvni,�}C7- <br /> ltf 2-6f� NNcPvLIS N1.nI qS.. �� Al; tz try��NDss�,�� <br /> E-Mail Address <br /> X n c- <br /> F <br /> (Permit Applicant Signature) (Date) <br /> An agreement/lease with the landowner that allows installation of the described sign and continued access to the sign site must be obtained prior to <br /> approval of this application for all categories except on-premise. Nothing herein requires a property owner to have or to retain a sign on their land. <br /> Landowner Name —Print Area Code—Telephone Number <br /> ILCV1V <br /> 05, <br /> Address,City,State ZIP Code y, �} <br /> By my signature, I acknowledge that I am aware of the Permit Conditions and Restrictions listed herein and I affirm there are no easements or <br /> restrictions tha would pro ibit thi gn from being erected. <br /> (Landown r ignature) (Date) <br /> Installer Name V, JAI(�n * License Number <br /> rTLw <br /> Address,City,State ZIP Code <br /> Z t'! 2-6 t 19 Vc +(J1 I�UUiI,'c' f't�Ll�, '44A/ `!d 6 <br /> Highway/s County/��� V't T `.& Town ❑ City ❑ Village Highway Side <br /> At'iIE1_S INN ❑S El El <br /> Land Zoning(Supply proof) Date of Zoning Sign to Face <br /> ("N 0 o0) ❑N ❑S El ❑W ❑ N\S XE\W <br /> Sign Location(Legal Description) '0ar! <br /> ,[hj 1/4 of the N W 1/4 of Section 3 Township North,Range 1' ❑ East West <br /> Distance from sign to the pavement centerline of the closest road that intersects with the highway along which the sign will be erected. <br /> (Feet) (East,West,North,South) (Identify road measured from) <br /> Distance from highway right of way to sign I Sign Illumination Height Above Ground Level(HAGL) <br /> 2 ft. Steady Light ❑No Light ❑Changeable Message <br /> Sign Category and Fee Sign Design <br /> ❑ On Premises Free Standing -$175 Type 1 (Choose one) Type 2(Choose one) <br /> ❑ On Premises On Building-$1,15 ❑ Single Face ❑ Side by Side <br /> ❑ Real Estate along Interstate-$175 ❑ Back-to Back Over Under <br /> Off Property-$175 '�Ek "V"Type ❑ On Building <br /> ❑ Service Club Meeting Notice—No Fee ❑ Does Not Apply <br /> ❑ Religious Meeting Notice—No Fee <br /> ❑ Agricultural Test Plot-$175 <br /> ❑ Sign on officially designated school bus stop shelter; <br /> Affidavit from school officials required-$175 <br /> ❑ Directional as defined by sec.TRANS.201.05 Wis.Adm.Code <br /> If box is checked,provide signature to the right-$175 <br /> ❑ Official(City,Village,Town,County,or State official to be applicant) (Agent Signature for Directional Attraction or Official) <br /> -------------If-- ox- <br /> b is- checked- ---,provide signature to the right _No Fee <br /> - ox - -- ---- -- --- ----------------- - ---------- -- - -------------------------------- <br /> - ------- ------------------------- <br /> Completed by Wisconsin Department of Transportation 1 a. r C ' I <br /> • Sign is on WisDOT Project No.6y710 ���" Z) (Approved for Director of Highway Operations) <br /> • Cancel existing permit as condition of issuing this permit? ❑ No gYes <br /> If the answer is"Yes",provide permit number and issue date U 7"t;UGZ j--`16 G`2 <br /> R.P. Number Inventory Sort Inventory Direction of Travel Highway Side Sign Area(Plus border&trim) <br /> z M t!,ZZ Highway70 <br /> Direction ` ❑N ❑S ES E ❑W qq Left ❑ Right 392- sq.ft. <br /> 660 ft.+from R/W Scenic Byway Check Number Trans.233 Setback Is4sue Date Permit Number <br /> ❑Yes allo 0 Yes Uq No r '7 ❑Yes ® No 15716 <br />