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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 64872 Office of Zoning Administrator w c o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> w O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and ? Ica <br /> as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the (D m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 Q. <br /> regulations of the State of Wisconsin. v <br /> C <br /> c <br /> OWNER 7 C` TELEPHONE �J� _ ��� 6 a � o. O <br /> o� <br /> a = <br /> ADDRESS <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) <br /> CONTRACTOR <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION p <br /> o <br /> SANITARY PRIVY X FILLING/GRADING CAMPING UNIT SUBDIVISION o � <br /> _ <br /> N <br /> STRUCTURE/ADDITION USE: —P <br /> (Home/Cabin;Comm i I Business; Bedroom;Deck;etc.) Z <br /> 0 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 (W),septic tank (ST), and drainfield (DIF). <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 /> 10 <br /> dated by the owner. 0 M <br /> 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 1 a U) <br /> PLOT PLAN Z Q <br /> o a <br /> M N <br /> o <br /> C <br /> M <br /> Gov <br /> a <br /> Cl) <br /> N <br /> A <br /> O <br /> _ <br /> C C� O <br /> j <br /> \ T;OI O 0 <br /> � z <br /> Nsw,�A) a,z <br /> o � � vd � Qov <br /> m — Qvs a m <br /> CONDITIONS OF PERMIT: <br /> m < C � <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. o CD o � <br /> F j T <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. _ m <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. O o <br /> $ aE C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o fD rn <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- vi m 0 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- o cNi, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n pt 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> T <br /> n x <br /> N N A N <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR EPhl6ftyJ $ <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o o m <br /> 88888 $ 88v <br />