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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 /> �'yCNL) <br /> Applicant-Sign Owner c'v.v i Area Code-Telephone Number <br /> Address,City,State,ZIP Code <br /> E-Mail Address <br /> (Permit Applicant Signatur (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 r <br /> a —Print Area Code—Telephone Number <br /> Address,City,State ZIP Code <br /> 2-- y 5C) <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 /> X <br /> (Landowner Signature) (Date) <br /> Installer Name License Number <br /> � v/-V_4& r IV t/ d�✓ �3 <br /> Address,City,State ZIP Code <br /> Highway/s C County �� Town ❑ City ❑ Village Highway Side <br /> •_3� �C�� c // L !V1� ❑ N ❑ S ❑ E W <br /> Land Zoning(Supply proof) Date of Zoning Sign to Face <br /> ❑ N ❑S ❑ E ❑W XN\S ❑ E\W <br /> Sign Location(Legal Description) <br /> /V&_1/4 of the%. 1/4 of Section 2 / Township _y�-'North,Range 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 /> 1.3I.Z 1:5�GU% i' <br /> (Feet) (East,West, North, South) (Identify road measured from) <br /> D'st.�nce from highway right of way to sign Sign Illumination Height Above Ground Level(HAGL) <br /> V— (o , 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-$175 ❑ Single Face ❑ Side by Side <br /> Real Estate along Interstate-$175 ','EJ� Back-to Back ❑ Over Under <br /> Off Property-$175 ❑ "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 box is checked,provide signature to_the right _No fee <br /> ----------- ------- -------- -------- ------------------ ------------------ �--�------ ----------------- <br /> Completed by Wisconsin Department of Transportation �ui -G/�`�G <br /> • Sign is on WisDOT Project No. 9010 7—2 1 (Approved for Director of Highway Operations) <br /> • Cancel existing permit as condition of issuing this permit? ELNo ❑ Yes <br /> If the answer is"Yes", provide permit number and issue date <br /> R.P.Number Inventory Sort Inventory Direction of Travel Highway Side Sign Area(Plus border&trim) <br /> Highway <br /> i hwa Direction [0 N ❑ S ❑ E ❑W Left ❑ Right <br /> 660 ft. +from RAN Scenic Byway Check Number Trans.233 Setback Issue Date Permit Number <br /> / J��j <br /> [:1 Yes No El Yes PS-No I 6 C 7 El Yes &No 0 G�7-2- <br /> L ( <br />