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M(mpl <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m _ o c <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m QO <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. H m <br /> w � <br /> c <br /> m O <br /> OWNERTELEPHONE f <br /> Tin g o in�sr.✓ _ — - .Sa/Z o <br /> VnN <br /> ADDRESSqV 5' -oN �i�T`E O -�A/ ��� .A'.✓O l�c �N�ry/� ` <br /> EMERGENCY/FIRE NUMBERROAD NAME ` <br /> a��gn 7, �J <br /> LEGAL DESCRIPTION (see tax receipt) a uT !oT 2 - 3 y 7-Yo N t IQ /b IV J'' <br /> CONTRACTOR <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION o <br /> n O <br /> SANITARY PRIVY FILLfNG/GRADING CAMPING UNIT SUBDIVISION o o <br /> STRUCTURE/ADDITION USE: C.4jgih/ Z11zA l <br /> (Home/Cabin;Commercial Business; Bedroom; Deck;etc.) !9icG Z o <br /> 0 0 <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 infest ofthefollowing:(a)buildingto 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. C o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. on a N <br /> 71 z co <br /> PLOT PLAN n o n <br /> m <br /> 1 cl <br /> -A F 2 I rIb 0 FT <br /> 11 Ch9 w co <br /> OJ \ C <br /> 0 <br /> n, <br /> l � <br /> /4 N <br /> 6htWM Q(c. <br /> a 0 Sl 4-#' (o �g-93 A X =fu 8 a f m <br /> w o 00 A9 v Y , k"/I/. 5'X-101 I' D$� 2.a y a. �o <br /> CONDITIONS OF PE MIT: c < S Z C S �rc r. <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. o F Loo. <br /> �� - <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. _E4 <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. �' i in m <br /> : $ : gE ' i C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o >a <br /> m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Q o : p <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 ; $`i3 $ <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 ON 0: <br /> access to the above described premises at any reasonable time for the purpose of inspection. 03i•' <br /> .._.. - (b m A w <br /> Ln <br /> r `Q'1 J*- <br /> M t w p <br /> SIGN HERE '� «r <br /> (s' a re of owns o building contractor) (date) <br /> o : <br /> ZONING ADMINISTRATOR 11 IN 1 7 g <br /> er Z.rnw�p,q -n p m <br /> TOWNSHIP PERMITS MAY BE REQUIRED O N N N N NT <br /> 0 :0 0 o fmA <br />