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I 5 i Htt i ��uu. � (Read "General Requirements" reverse side) <br /> Name of applicant "" ' '� T'`�I � 2' ��� ��"S Phone ��S�31 S'� <br /> •. /O 7/ C� `�Z /�t� �-+ ak,�J �3� <br /> Address 3� 1 o s �k�. �-�- d'' 6''�p <br /> city) (state) l 6 � � lzip code <br /> 1/J �...'���.�.1-- ��'E-ec'-S Address 3'"-a.�--` �4..t.�.-z.�. � �'t� JZ <br /> Name of Property Owner �,c��--�„� <br /> r, S S a� �3 / <br /> 1. Contractor performing work (If Known) l ��' �n Phone <br /> 2. Application is hereby made for permission to construct and thereafter maintain: Driveway Public Street(s) <br /> 3. Building to be constructed: � Yes �No � Residence o Commercial (Specify Type) <br /> 4. Driveway or street wil� be: � Temporary �-Permanent Date proposed entrance wili be needed: G ` � ` �� <br /> 5. Is the ro ert �Platted � Un latted Number of resent drivewa s or entrances to ropert a" �T� �� 3� <br /> P P Y� P P Y P Y� <br /> 6. Building Permit acquired: � Yes o No City O�"' � Permit No. <br /> 7. Type of proposed entrance surface. �Bituminous � Concrete o Rock � Other <br /> 3-1 10 �3'�r S [ � !2� �r �-r � <br /> 8. Location • <br /> (Address) (Co. Road) (City) <br /> 9. Location, if rural: Miles of <br /> (N.,S.,E.,or W.) d or Street) <br /> Dated 3 � Applicant's Signature <br /> Printed Name � <br /> TO HELP THE INSPECTOR,PLACE A STAKE WITH A CLOTH ATTACHED IN THE CENTER OF THE PROPOSED ENTRANCE,HIGHER THAN <br /> ANY SURROUNDING VEGETATION. <br /> APPLICANT'S DIAGRAM - (If plot or construction plan is not submitted) <br /> SCE � ��-�� .� S/��-rc���.s <br />