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Docusign Envelope ID:DEB51066-B701-4865-A8C8-07762EAD0107 <br /> LAND USE PERMIT APPLICATION —Burnett County, WI a, c <br /> Applicant Complete All Sections BeloN% This Line ;3, A <br /> Permit Types and Fees(Please,check appropriate boxes) - <br /> Dwelling/Principal Structure $300 Addition/Alteration to Dwelling/Principal Structure $200 <br /> v <br /> Commercial/Industrial Structure $300 Addition/Alteration to Commercial/Industrial Structure $200 <br /> Accessory Structure(Garage,Shed,etc.) $150 Addition/Alteration to Accessory Structure $150 <br /> a <br /> Accessory Structure(Commercial/Industrial) $200 Addition/Alteration to Bunkhouse $150 <br /> C <br /> Deck/Stairs/Patio/Retaining Wall/Sidewalk Bunkhouse $250 <br /> Driveways/&Campground Structures $125 WI State Statute 59.692(ly)Structures $350 r <br /> Filling/Grading $150 Boathouse $500 <br /> Solar Panels(Stand alone or roof mounted) 1$1501 1 Permit Extension(1 Year Extension-Allowed Once) $100 <br /> NOTE:After-the-fact permits(permit acquired after construction has begun)may cost up to three times the normal fee. i <br /> V <br /> `Communication Towers,Camping Permits&Signs require a different application form,see corresponding application,and fees. !, <br /> 3 <br /> 'Items not listed above will be treated as accessory structures,such as:pergolas,landscaping,etc. <br /> z <br /> ��"" c <br /> Property Owner's Name: t✓��+ l,�oW exN M <br /> 0 <br /> Property Owner's Mailing Address: S 19 0 K- dQA RA 010 Url+ Y-drA Uj k ci 315 12 1n <br /> Citv State Zip <br /> Property Site Address: a19%W Rd n h(AV-�j k-Z l 5t'Q'3d <br /> Contact's Telephone number: U08-q 5c2079 5- <br /> Contact's Email: `f"V OLV- , LY' 535'7a qohoO, Y r <br /> *If staff has a question about this application, will be contacted via email. Make sure your email address is N -_1 <br /> legible and your email provider will accept emails from the following address:GBurnettCountyWi.gov <br /> _ Y 1 <br /> Legal Description 01'Property: S W 9 W 4f)( is u-0 00' F-X Csm V/ l9 P 3j 14 <br /> Section is: Town : Kt N Range ti: 15 W Town of: SW 3S J <br /> *Attach additional page if needed for le+rgthY descHption OR attache copy gfthe deed OR attach tax system proper7v page.' <br /> L1J .fit F i <br /> Tax ID;1(I-5 digit number;found on tax statement): Lj 15 � c <br /> Proposed Use of Structure/Addition: PV so10r !re)tAnA Imourct - <br /> Anticipated Start Date: //O V- 400a rHome/Cahin;Commercial Business;Bedroom;Deck:eic.) <br /> Building Contractor: C)OVt I.WY JeOrl Sewer installer: ^ <br /> s � <br /> AREA BELOW THIS LiNE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY = z <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: � x <br /> c <br /> s <br /> r <br /> =. Fee Ree: � <br /> Check <br /> z <br /> Date of staff site visit: 2I (.V2 Initials of site isit staff: 1--T ✓9 > r- <br /> APPROVED BY LAID SERVICES OFFICIAL DATE:I I ZZ/zXg �CO <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF <br /> Cn 0 <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT o N <br /> Page 1 of 5CD <br /> Burnett Count', Wl Land Use Application- Rev 04/2024 u <br />