Laserfiche WebLink
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 /> SC'l41)3E-1�T <br /> Applicant-Sign Owner G%%•^/T! .T- Area Code-Telephone Number <br /> Address,City,State,ZIP Code <br /> E-Mail Address <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 Nre —Print Area Code—Telephone Number <br /> 6 �/ s <br /> Address,City,Stale ZIP Code <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 that would prohibit this sign from being erected. <br /> (L ndowner Signature) (Date) <br /> Installer Name License Number <br /> Address,City,State ZIP Code n <br /> Highway/s County-,� Town ❑ City ❑ Village Highway Side <br /> S� L�fZ�/4t ❑ N ❑S KE ❑W <br /> Land Zoning(Supply proof) Date of Zoning J� Sign to Face <br /> C! !j �- 2.'5__. 7 ❑ N S ❑ E ❑W ❑ N\S ❑ E\W <br /> Sign Location(Legal Description) / <br /> 1/4 of the 40 1/4 of Section 2 Township I/ONorth, Range_ZOL❑ East X 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 /> u Al T'1 ✓ /) G/ <br /> (Feet) (East,West, North,South) (Identify road measured from) <br /> Distance from highway right of way to sign Sign Illumination Height Above Ground Level(HAGL) <br /> 0 z I15 / ft. Steady Light ❑ No Light ❑Changeable Message /0 ft. <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-$175 Single Face ❑ Side by Side <br /> ❑, Real Estate along Interstate-$175 Back-to Back ❑ Over Under <br /> Off Property-$175 ❑ "V"Type ❑ On Building <br /> ❑ Service Club Meeting Notice—No Fee jE) 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 box is checked,_provide signature to the right__No Fee____________________________________________ <br /> Completed by Wisconsin Department of Transportationli� <br /> • Sign is on WisDOT Project No. (Approved for Director of Highway Operations) <br /> • Cancel existing permit as condition of issuing this permit?2�No ❑Yes <br /> If the answer is"Yes",provide permit number and issue date <br /> R.P. Number Inventory Sort Inventory Direction of Travel Highway Si a Sign Area(Plus border&trim) <br /> Highway 3 Direction N AN'❑S ❑ E ❑W ❑ Left X Right sq.ft. <br /> 660 ft. +from R/W Scenic Byway Check Number Trans.233 Setback Issue <br /> � Date Pe miiyt N"jmber <br /> [:]Yes [A No El Yes (3No JET b0 0Yes [JNo �J�-z�-�U� �"q 5-21 <br />