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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 5� I O �; <br /> APPLICATION FOR — LAND USE — PERMITS m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and o c <br /> located as shown herein. The undersigned agrees that all work stall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and �_ $ IS <br /> regulations of the State of Wisconsin. a m <br /> c m <br /> $ O <br /> OWNER Paul Kelly TELEPHONE (612) 455-3908 0 <br /> r_ <br /> ADDRESS 7335 Degrio Way Inver Grove Heights, MM 55076 ° <br /> EMERGENCY/FIRE NUMBER ROAD NAME South Shore Drive <br /> c <br /> LEGAL DESCRIPTION (see tax receipt) Lot 5, Bass Lake Shores, Section 23, T40N, R17W, Town <br /> ot Union <br /> CONTRACTOR <br /> 1 <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITIONLC <br /> o <br /> n 0 <br /> SANITARY K PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION o 0 <br /> J <br /> e � <br /> STRUCTURE/ADDITION USE: Sanitary Only ° <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) 43 <br /> z o <br /> 0 c <br /> Q.. a <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) ` <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). <br /> 3. Show dimensions In feet of the following:(a)building to all lot Innes,(b)building to center line of road,(c)building yy <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. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 1A 3 to <br /> c <br /> _ Z v <br /> PLOT PLAN o <br /> n O <br /> f� N. <br /> C 6- , <br /> a <br /> as <br /> `o <br /> C <br /> r <br /> ,i r1 N <br /> VI �_ <br /> O O <br /> SEE ATTACHED <br /> o <br /> m ,b <br /> r� <br /> O � y <br /> w <br /> Z <br /> (V y <br /> J <br /> g g a <br /> CONDITIONS OF PERMIT: v 3; Z 9C <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. p �'Z i 1 <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. ^�„: N• <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. m p m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- "'Si�' m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor• <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I (J? ? $ $ E <br /> further accept all liability which may be a result of the County of Burnett relying on this Information 1 am providing in this ap• i , <br /> plication.1 agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m <br /> r : <br /> Wade Rufsholm 10/17/94 <br /> SIGN HERE ` ""• <br /> (signature of owner or building contractor) (date) ; <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDYI m <br /> &&� <br /> ry$ 8 $ 8i818 ai <br />