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IN ctxw, , <br /> Buf^ett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U T -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> W o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and io <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the MC <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> m m <br /> C <br /> 0 <br /> OWNER A/� K 9�L� E LNC % G TELEPHONE r � 1Z <br /> ADDRESS L/ 1 .-U — P 7� A✓l So - Sit- ST- PA4 /}\Mn/ / SSD 17 S- O m <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> .3 s4A <br /> LEGAL DESCRIPTION (see tax receipt) (71 <br /> CONTRACTOR di <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE X — ADDITION X— p <br /> 0 <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT n SUBDIVISION O <br /> o ^- <br /> STRUCTURE/ADDITION USE: �(� �� ) — �-� — -�C')� o _ <br /> (Home/C�bA,Commercial Business; Bedroom; Deck;etc.) Z <br /> 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). 1. <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). o <br /> 3. Show dimensions in feet ofthefollowing:(a) building to all lot lines,(b)building to center line of road,(c)building T <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 <br /> O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE ISSUED 0 a (n <br /> PLOT PLAN o a <br /> I <br /> wee fid_ Pilo-, Pct w � � <br /> m � I- <br /> See- <br /> I N <br /> m <br /> 0 <br /> II� <br /> N <br /> O <br /> J <br /> O <br /> 1 <br /> N <br /> Z <br /> G <br /> M ii(n -0(nr O '7 <br /> a ..0 f m <br /> CONDITIONS OF PERMIT: v m Z; iu c 0 m' <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. m ? <br /> z m' o': i <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. o F 5i '-�- <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. N' 0 m <br /> o : <br /> $ O <br /> �E C <br /> I 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- `w m xr <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 m is $ m <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. 0, m <br /> N Q A N <br /> SIGN HERE lo <br /> (signature of owner or buildin contractor) (date) <br /> ZONING ADMINISTRATOR (_-rc�� $ <br /> H� m <br /> TOWNSHIP PERMITS MAY BE REQUIRED O N fNll N � N p N m <br /> $ $ $ $ $ $ $ $ y <br />