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I 'r <br /> Burnett County 7410 Co. Rd. K, No. 102, Sinn, WI 54872 Office of Zoning Administrator Ua $ c <br /> APPLICATION FOR - LAND USE - PERMITS m <br /> TO THE ZONING ADMINISTRATOR:The undersigned dere makes 4 <br /> g by application for a Permit for the work described and � v <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the u <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and $ Vn <br /> regulations of the Stale of Wisconsin. m m <br /> C g <br /> m /£ <br /> OWNER Ronald Freese TELEPHONE (715)349-7376 n /V <br /> o = <br /> ADDRESS 5415 Culbertson Road Webster, WL 54893 <br /> EMERGENCY/FIRE NUMBER 5415 ROAD NAME Culbertson Road , v <br /> n <br /> LEGAL DESCRIPTION (see tax receipt) pct. NE NE, Section 7, T38N, R15W, Town of LaFo tette i7 n <br /> CONTRACTOR r) <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION p <br /> m' <br /> SANITARY % PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION e <br /> o <. <br /> STRUCTURE/ADDITION USE: Sanitary Only o <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> z o <br /> 0 c <br /> m <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or tap view) <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate No Ift (N). <br /> 2. Show the location of the well (W),septic tank (ST), and dralntield (DF). o <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,( )building <br /> measurement to the ordinary high water mark of lake,stream,or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 1A v y <br /> PLOT PLAN _ <br /> C X = <br /> 111 <br /> SEE ATTACHED � <br /> O <br /> N <br /> O <br /> _ <br /> O rJ <br /> _ <br /> m <br /> O � <br /> N <br /> Z <br /> 1 <br /> F <br /> CONDITIONS OF PERMIT: <br /> V $� c S <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT INis <br /> SSUANCE. Z o ? Z 1 <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. p <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. rr� <7 , In <br /> $ Et O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i <br /> edge and belief it is true,Correct and Complete.I acknowledge that I am res y m <br /> g p g responsible for the detail and accurst of II informs- - <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize the this infor- ` i B ; <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I CCS = 8$ $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providin In this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized pe on to have o <br /> access to the above described premises at any reasonable time for the purpose of inspection. j ` g <br /> i � a <br /> SIGN HERE <br /> Wade Rufsholm 5/8/95 <br /> (signature of owner ildi g t t d (date) . <br /> ZONING ADMINISTRATOR p 8 <br /> TOWNSHIP PERMITS MAY BE REOUIRED «( m <br /> $ 88888 w <br />