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O)l cAop .o, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3. _ <br /> d O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> m 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. v <br /> w m <br /> w � <br /> OWNER11_f/ TELEPHONE � / a FO <br /> J7�j (7 m <br /> ADDRESS D �-- <br /> Aa <br /> EMERGENCY/FIRE NUMBER ('�^ �r ROAD NAME <br /> ✓5/TT <br /> re <br /> LEGAL DESCRIPTION (see tax receipt) a// � L, 'l_ —j�9)- yl-rS- n <br /> CONTRACTOR <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION p <br /> � <br /> SANITARY PRIVYo FILLING/GRADING CAMPING UNIT SUBDIVISION a � <br /> STRUCTURE/ADDITION USE: l t n <br /> (Home/CaOn;Commercial Business; Bedroom;Deck;etc.) Z <br /> o ° <br /> 0 <br /> m <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 (yi), septic tank (ST),and drainfield (DF). <br /> 3. Show dimensions infeet ofthefollowing:(a)building to all lot lines,(b)buildingto center line of road,(c)building -q <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. O o <br /> NOTE: BUILDING/ STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. an 3 y <br /> PLOT PLAN 10 Z <br /> A � a <br /> m <br /> C <br /> a <br /> I <br /> Q <br /> N W <br /> 6 � <br /> o <br /> w <br /> f Z <br /> 1, <br /> G <br /> CONDITIONS OF PERMIT: c Q.-m <br /> < w 2 N J <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. e m 0 . m <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. <br /> Ni € Lj2 i m <br /> ja <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- an m m <br /> tion contained in this application(including an accompanyingschedule and I further declare that I recognize that this infor- <br /> mation <br /> ( 9 Y 1 9B g 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.1 agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the abovtleacriDetl premise ny reasonable time for the purpose of inspection. m 'No m <br /> mvAo <br /> T m <br /> SIGN HERE <br /> o : <br /> ( ' n tur of own r df ntractor) Oat « <br /> / [ o [ <br /> ZONING ADMINISTRATOR / �/ , 0 <br /> «fn rn�rn en Nw tnT <br /> TOW SHIP PERMITS MAY BE REQUIRED O In en N N 0 p N m <br /> 00000000u) <br />