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OUTDOOR SIGN INSTALLATION APPLICATION AND PERMIT ��CAap A.lic�tioPoollockct office <br /> Wisconsin Department of Transportation District 8 Sign Permit <br /> DT1680 2001 (Replaces EM417) This Permit is RevocableOOrC�j►1��C; <br /> For Locations Adjacent to Interstate and Federal Aid Primary Highways 1701 N. 4th St. <br /> and the National Highway System r G' ra � o � 54 <br /> So <br /> 1.Applicant-Sign Owner Telephone Number 2.Installer License Number <br /> Address 2 Address <br /> 0 Box n <br /> City,State,Zip Code E-Mail Address City,State,Zip Code <br /> �s c�RG Wes. Vd r. <br /> 54 <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 approval of this <br /> application for all categories except on-premises and official. Nothing herein requires any property owner to have or to retain any sign on their land. <br /> 3.Landowner Address City,State,Zip Code <br /> tToHA) )40- T� 5o� god 7, ) i4?t),8�' � <br /> B signing bel , I acknowledge that I am aware of the Permit Conditions and Restrictions d herein. <br /> (Sin ure of Landowner) (Date) (Si ature o ermit Applicant) (Date) <br /> 4.Highway/s 5.County E; own ❑ City ❑ Village 7.Highway Side <br /> ulwe* Lc11 SS7 ❑ N AS ❑ E ❑W <br /> 8. Land Z ing(u p proof) 9.Date of Zoning 10.Sign to Face <br /> 7l0 ❑ N ❑S ❑ E X_ <br /> W ❑ N\S ❑ E\W <br /> 11.Sign Location Legal D scription) C p 1/4 of the!�� A)1/4ofSection 2,9 Township IjK4North, Range/.!�_4/❑ EastX West <br /> 12,Distance from sign to the pavement centerline of the closest road that intersects with the highway along which the sign will be erected. <br /> 6�S 14 /E5i' 10A (L Sf <br /> (Feet) (East, est,North,South) (Identify road measured from) <br /> 13.Distance from the highway right of way 14.Sign Illumination ❑ Steady Light XNo Light 15.Height Above Ground Lev I(HAGL) <br /> L�f to sign: I ft. ❑Changeable essage <br /> vY ft. <br /> 16. Sign Category and Fee 17. Sign Design <br /> ❑On-Premises Free Standing -$175 Type 1 (Choose one) <br /> ❑On Premises On Building-$175 Single Face <br /> ❑On Premises Internal Traffic Guidance—No Fee ❑ Back-to Back <br /> Off Property(Must provide landowner information)-$175 ❑ "V"Type <br /> ❑Service Club(Must provide landowner information)—No Fee <br /> ❑Religious(Must provide landowner information)—No Fee Type 2(Choose one) <br /> ❑Agricultural Test Plot-$175 ❑ Side by Side <br /> ❑Sign on officially designated school bus stop shelter; ❑ Over Under <br /> Affidavit from school officials required-$175 &Does Not Apply <br /> ❑ Directional as defined by sec.TRANS.201.05 Wis Adm.Code <br /> (Must provide landowner information) <br /> If box is checked, provide signature to the right.-$175 <br /> ❑Official(City,Village,Town,County,or State official to be applicant) (Signature of Agent for Directional Attraction OR Official) <br /> If box is checked, provide signature to the right. -No Fee <br /> ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> Cor i [ete ns to. i= xtewat of T%ar 41 <br /> /� <br /> By <br /> • Sign is on WisDOT Project No. /03- 56 a" "' (Approval for Director of Highway Operations) <br /> • Cancel existing permit as condition of issuing this permit? ❑ Yes EyNo If yes: Permit# Issue Date <br /> R.P. Number Inventory Sort Inventory Direction of Travel Highway Side Sign Area(Plus border&trim) <br /> 00+ 1, Highway Direction ❑N ❑ S L4 E ❑W ❑ Left X Right Z.S sq.ft. <br /> ?7 6=_ <br /> 660 ft. +from R/W Scenic Byway Check Number Issue Date Trans.233 Setback Permit Number <br /> ❑ Yes [g No ❑Yes No U 718 D c- 20,OS_ ❑Yes R No ' 9 + <br />