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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ( U D o( a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 0 c <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ¢ <br /> regulations of the State of Wisconsin. �, d <br /> w <br /> c <br /> OWNER /y`?PELEPHONE <br /> ADDRESS <br /> 1 <br /> EMERGENCY/FIRE NUMBER G/ ROAD NAME (J <br /> LEGAL DESCRIPTION (seetaxreceipt) <br /> CONTRACTOR <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE�_ ADDITION <br /> o ✓✓ <br /> SANITARY PRIVY FI LING/GRADING '/ CAMPING UNIT SUBDIVISION o ` Q <br /> �7 ��r�, / m r- <br /> STRUCTURE/ADDITION USE: Clr�c�t O r� ° o <br /> (Home/Cabin;GoInmercial Business; Bedroom; Deck;etc.) Z o <br /> 0 c <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 drainfleid (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. C o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. on 3 m <br /> 71 z c <br /> PLOT PLAN n 0 ¢ <br /> m �^ <br /> ULc ' <br /> m <br /> t a <br /> I <br /> 0 <br /> IN — �0 <br /> o <br /> N 1^ 1 <br /> Z <br /> Z <br /> G <br /> ¢ � m <br /> CONDITIONS OF PERMIT: <, R o <br /> t. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. o F T'z a <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. = zt I m <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. : O » I O <br /> g € c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i 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- 0 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> P 110 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 <br /> access to the above.described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERa '. <br /> (signature of or in co tort Id 1 0 [ s <br /> ZONING ADMINISTRATOR Z g <br /> TO NSHIP PERMITS MAY BE REQUIREDJ 8 8 8 m <br /> N o N o o m <br /> gggggg99M(n <br />