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• <br /> LAND USE PERMIT APPLICATION — Burnett County, WI a r <br /> Applicant Complete All Sections Below This Line 0 t� <br /> Permit Types and Fees:(Please,check appropriate boxes) e G,j. <br /> Dwelling/Principal Structure $300 .x Addition/Alteration to Dwelling/Principal Structure $200 K 4-' <br /> R.7 <br /> _ Commercial/Industrial Structure $300 Addition/Alteration to Commercial/Industrial Structure $200 'OSp <br /> X Accessory Structure(Garage,Shed,etc.) $150 Addition/Alteration to Accessory Structure $150 9 OD <br /> Accessory Structure(Commercial/Industrial) $200 Addition/Alteration to Bunkhouse $150 v1 <br /> Deck/Stairs/Patio/Retaining Wall/Sidewalk Bunkhouse $250 <br /> Driveways/&Campground Structures $125 WI State Statute 59.692 1v Structures $350 S <br /> Y / pg ( ) Sb <br /> Filling/Grading $150 Boathouse $500 S <br /> Permit Extension(1 Year Extension-Allowed Once) $100 R <br /> *NOTE:After-the-fact permits(permit aquired after construction has begun)may cost up to three times the normal fee. J <br /> *Communication Towers&Signs require a different application form;see corresponding application,and fees. '' /. <br /> *Items not listed above will be treated as accessory structures,such as:pergolas,landscaping,etc. o <br /> Property Owner's Name: E.M E S A. CHURCH E. a, <br /> Property Owner's Mailing Address: 2.3 ! Co C- ET'S L D R h/E-3-AX d F ri. .32.2.163 CA s" <br /> City State Zip o <br /> Property Site Address: 14-8! HAMS ROAD- SF'OOMER r WI I S4410 ! . g. <br /> 904 -417- 62 .8 d <br /> Contact's Telephone Number: ro <br /> Contact's Email: CI4U!J A C coml.CPti ST „ NI E.T <br /> Legal Description of Property: SW /4 0 F N E 14 / SEC ! !iT 40K)1 R!..1W d <br /> Section#: 11 Town#: 4'0 N Range#: i '1* W Town of: 5 C.Q : <br /> *Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page. <br /> Tax ID#(1-5 digit number;found on tax statement): 17 888 <br /> Proposed Use of Structure/Addition: <br /> SC-ASOMAL Goll' N 4 (0r4,7e- l)3H t <br /> Anticipated Start Date: 6 -- 1 ^ 2 ?07 (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> Building Contractor: LYNN \11QI! 1 Es! Sewer Installer: RICKS FLUM S d M Cr <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br /> **The applicant needs to contact their UDC Inspector to determine if a permit is needed from them prior to <br /> ANY construction taking place for any dwellings,dwelling additions,manufactured homes,manufactured <br /> home additions,and bunkhouses.** � <br /> lneeAekti 5eTG � '0.1rage 1 J h1iGFL �'*L4 <br /> i ,- <br /> aD j&1, ,04- 4, exze I J(LO/,qShit/ ifl 6 q to 51 CJ y Fee Rec:ntd5) <br /> x <br /> Check#: fig <br /> Date of staff site visit: 61 I/2-? Initials of site visits ,f op <br /> q)/61- r 1L /50 :Alio <br /> APPROVED BY LAND SERVICES OFFICIAL: / DATE:6/a0/z� • ! o <br /> or- <br /> UPON APPROVAL: APPLICANT UST POST COPY OF .... 05 <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT3 <br /> w 0cru <br /> Page l of 5 •w g <br /> Burnett County,WI Land Use Application—Rev 12/2021 ; � ^' <br />