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Burnett County,7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c a <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and i o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin, y m <br /> w <br /> OWNER TELEPHONE o. C>* <br /> Jack Co2v�n <br /> ADDRESS 12381 Hummingbind Strteet Coon Rapids, MN 55443 <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) Lot 4 TottandeA AcAeh, Section 23, T40N, R16W, Town o4 <br /> CONTRACTOR aan ^ l <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGEIACCESSORY STRUCTURE ADDITION I p <br /> O <br /> SANITARY_X PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 0 e <br /> N O <br /> STRUCTURE/ADDITION USE: $aft<tQh[+ y,'Itv 5wIdInQ ,n i A4ache o �' <br /> (Home/Cabin;Commercial Business;Bedroom; eck;etc.) Z <br /> 0 ° <br /> v <br /> 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 drainfield (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 <br /> dated by the owner. o 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSfTE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 1I 3 u, <br /> c <br /> PLOT PLAN o 'n <br /> m o <br /> C <br /> M <br /> 0 <br /> SEE ATTACHED W <br /> I N <br /> m <br /> 0 <br /> 0 <br /> N <br /> O <br /> J <br /> b <br /> O y <br /> N <br /> Z <br /> S <br /> G <br /> m O c m m p g m <br /> N D _ m a ie <br /> CONDITIONS OF PERMIT ^ 0. m5. o � ,0 <br /> Z m ' <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. o F : E 21 <br /> '2 <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE, 21 N � i m <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. tR : i g m 2 i C c : <br /> a , <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o' : m � m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- I w m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Sm v, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. m $ <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 i L 0 p <br /> access to the above described premises at any reasonable time for the purpose of inspection. $ o <br /> M i A N <br /> 8 , <br /> SIGN HERE (Dade Ru4aho& _LL1 l`12-� 8 . <br /> m <br /> (signature off downer or building contractor) <br /> ZONING ADMINISTRATOR ltm 1�Lf�tiiFiPrA� III D ��5- - <br /> TOWNSHIP PERMITS MAY BE REOUIRED P ; AUG 19 I99? N N N o o m <br /> 11,),I 888 8888 ) <br />