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Burnett County 741,0 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m ; o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> m s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the $ <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and _ <br /> regulations of the State of Wisconsin. w m <br /> m m <br /> OWNER _ TELEPHONE i O <br /> E <br /> G r=lZ r=• i ) / -/_ �1 f— 'gyp <br /> ADDRESS '� g <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) ,; o <br /> /�� <br /> CONTRACTOR <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION o 0 <br /> O <br /> SANITARY PRIVY_ FILLING/GRADING CAMPING UNIT SUBDIVISION o <br /> I <br /> » <br /> STRUCTURE/ADDITION USE: r'i ,� R'i V"vl14o � <br /> (Home/Cabin;Commercial Business;Bedroom; k;etc.) Z o <br /> 0 0 <br /> a <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). r <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). e <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 9 <br /> dated by the owner. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSrrE VERIFICATION BEFORE A PERMIT CAN BE ISSUED. 1I o to D <br /> PLOT PLAN Z v T <br /> � o n <br /> O 5. <br /> O <br /> C <br /> JQ <br /> N <br /> m <br /> n <br /> O <br /> 1 <br /> 0 I� <br /> O � <br /> N IIr� <br /> » I <br /> I = <br /> tel`\T <br /> <V <br /> G <br /> TI <br /> W. ag as em 33 <br /> CONDITIONS OF PERMIT: a- a e m <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. 0 4 0 ? ' �� <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. Zii O m <br /> 10 <br /> PP (including Yaccompanying 1 Y Y g; C <br /> I declare that this application includin an schedule has been examined b me and to the best of m knowl- S f m m E <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- yy!!o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> motion 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g e 8 <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- w <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have O <br /> access to the above described premises at any reasonable time for the purpose of inspection. n <br /> T : x: <br /> m p + m y :' i <br /> SIGN HERE J� . 2. , r %. / c�. r'� ` E X{a eg E i <br /> ( nature of owner or building contractor) (date) 8 ; a <br /> 8 Fr i <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED 901000100 1G m <br /> $ 888 $ 888m <br />