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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator ; ; /o <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned here makes m o <br /> g by application for a Permit for the work described and a <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirementof the o 'n/ <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County with <br /> and the laws and �/ <br /> regulations of the State of Wisconsin. o m <br /> c m j <br /> OWNER Nark Harmon TELEPHONE � <br /> E <br /> o ' <br /> ADDRESS 8216 Oregon Circle Bloomington, NN 55438 m <br /> EMERGENCY/FIRE NUMBER ROAD NAME Thompson Bay Road <br /> LEGAL DESCRIPTION (see tax receipt) <br /> Lot 1, CSM Vol. 14, Pg. 123, G.L. 2, Section 36, TON, <br /> CONTRACTOR <br /> R15W, Tow-0 of Jackso <br /> n <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION o t� <br /> n O 3 <br /> SANITARY $ PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISIONp 0 Q <br /> ° <br /> '^ r <br /> STRUCTURE/ADDITION USE: ° <br /> (Home/Cabin;Commercial Business; Bedroom;Deck;etc.) zo <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 (VV),septic tank (ST),and drainf laid (DF). <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)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 9 <br /> dated by the owner. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSrrE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 7i o <br /> PLOT PLAN <br /> O ° <br /> o <br /> � r <br /> SEE ATTACHEDO <br /> � G <br /> N <br /> m <br /> Q y <br /> u <br /> ^ I(D <br /> M <br /> l <br /> So <br /> I� <br /> T� � W M <br /> CONDITIONS OF PERMIT: >C <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. q <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. ` �Q' ` `• O O <br /> 4 ' <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of y knowl qi! i <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of a I informa- m "E R1 <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that his infor- $ $ p <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue permit. 1 $ $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing In this ap- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have o E <br /> access to the above described premises at any reasonable time for the purpose of inspection. .n <br /> $ OR ? m <br /> SIGN HERE <br /> Wade Rufsholm ` - <br /> (signature of ow r bui In tr (date) ry. <br /> g <br /> ZONING ADMINISTRATOR ` g ' <br /> TOWNSHIP PERMITS MAY BE REOUIRED 1;1 RE m <br /> rn <br /> $8 8888 UU) <br />