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btomp <br /> Burnett County 7410 Co. Rd K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o a <br /> APPLICATION FOR — LAND USE — PERMITS3 ' — <br /> d o <br /> TO THE ZONING ADMINISTRATO :The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The and rsigned agrees that all work shall be done in accordance with the requirements of the '^ 0 <br /> Burnett CountyLand Use Ordinance,Sanitation Code, and with all other 3 n ` 1 <br /> applicable County Ordinances and the laws and .N <br /> regulations of the State of Wiscons n. H m <br /> µ� �j�� n <br /> ' ' / m O <br /> OWNER rI, o• e P C� TELEPHONE ' &— 57`��lJ �m f <br /> o ' <br /> Mama , <br /> m m <br /> ADDRESS ' <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION (see tax receip <br /> CONTRACTOR r Y <br /> v ""S <br /> TYPE OF PERMIT(S): DWELLING/BU LDING GARAGE/ACCESSORY STRUCTURE ADDITION o �` <br /> L) <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION0 <br /> o < <br /> STRUCTURE/ADDITION USE: (13 <br /> o <br /> (H me/Cabin;Commercial Business; Bedroom: Deck;etc.) Z o <br /> 0 0 <br /> DIRECTIONS FOR PLOT PLAN I RAWING: (Aerial or top view) <br /> 1. Show the location and size ol 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 infeet of the following:(a) building to all lot lines,(b)buildingto center line of road,(c)building -0 <br /> measurement to the ordinary iigh water mark of lake,stream, or river. <br /> 4. If separate plans are submitte J by an architect,engineer,builder,contractor,etc.,the plans must be signed and - <br /> dated by the owner. o <br /> NOTE: BUILDING/STRUCTURE LOCAT ONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 71 a N <br /> 71 z Q <br /> PLOT PLAN 0 n <br /> M o <br /> M �c <br /> V 139 -00 b <br /> n <br /> 0 <br /> 0 <br /> N <br /> O <br /> Q y <br /> w <br /> Z <br /> I <br /> is <br /> Acc� r Dci aF <br /> E m m <br /> D m<,: N 0 j <br /> CONDITIONS OF PERMIT: < m Z ii 0 Qr.1. DRIVEWAY MUST MEET DRI EWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. a C 9 Q y, 1 <br /> 2. REMOVAL OR CUTTING OF rREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. 9 <br /> 3, NO GRADING OR SHORELA D ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. r" 0 : O <br /> I declare that this application(inc uding any accompanying schedule)has been examined by me and to the best of my knowl- ^i <br /> edge and belief it is true,correct i nd complete.I acknowledge that I am responsible for the detail and accuracy of all informa- "1 «�m m <br /> tion contained in this application including any accompanying schedule)and I further declare that I recognize that this infor- `,8 is p <br /> mation I am providing will be rel ad upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <br /> further accept all liability which or ay be a result of the County of Burnett relying on this information I am providing in this ap- ' i `n <br /> plication. I agree to permit count officials charged with administering county ordinances or other authorized person to have i iO o, p <br /> access to the above described p mises at any reasonable time for the purpose of inspection, m 3 'oo M <br /> m 0 O <br /> M N <br /> SIGN HERE <br /> (sign kture of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR J r $ : X <br /> TOWNSHIP PERMITS MAY BE REQUIRED $ o o g o N <br /> 0 <br />