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0)q C1_yly� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator ° o <br /> - o <br /> APPLICATION FOR LAND USE PERMITS 3 4 <br /> r <br /> i o <br /> OWNER <br /> t✓FJV 5 r- GA ro�� (/4) / � TELEPHONE 7!5, '/ —y <br /> m <br /> /, <br /> HOME ADDRESS 2 3 63 T1� --)*5`-4KJ �44keTk9r"1 <br /> r Q <br /> 0 <br /> EMERGENCY/FIRE NUMBER Sof ROAD NAME J3,1V4 t,y Z4k& <br /> LEGAL DESCRIPTION(see tax receipt) <br /> eou'-" (0-f 3�-I�f <br /> 0 <br /> or <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-4�;)6 <br /> CESSORY STRUCTURE ADDITION rr <br /> ' \\ a <br /> 5. <br /> a <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> ca <br /> STRUCTURE/ADDITION USE: � ES <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> See � c j <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) of T <br /> FL <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 'p <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C .. n <br /> NORTH(N). y 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> STREAM OR RIVER. <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS,ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N I <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS <br /> MUST BE SIGNED AND DATED BY THE OWNER. c <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE q ° ) <br /> ISSUED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN 75 FEET OF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> X 'anrRpv�o10 <br /> tOa m <br /> 6. �'� mcu`" 3 <br /> 7. o <br /> =y: m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that 1 am responsible for the detail and accuracy of a g <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize rn m <br /> E m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this information I am m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other m E E <br /> authorized person to have access to the above descrl ed premises at any reasonable time for the purpose of Inspection. <br /> -n : i <br /> m : <br /> � m <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR u 1 m -Fran I ODQ <br /> IN71 N O O <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o o 0 <br />