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00) Ca, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator m o r`p 0 <br /> APPLICATION FOR LAND USE PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work y <br /> described and located as shown herein. The undersigned agrees that all work shall be done in actor- = ` <br /> dance with the requirements of the Burnett County Land Use Ordinance, Sanitation Code,and with all other 3 <br /> 0 <br /> applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> OWNER ELEPHONE <br /> l�o�AG�SCARD Dl Rip,4r/Gf,ejev&Jr 2,1 ��i6 �7// o �• <br /> HOME ADDRESS 27 1,33 L 'ee k1�,- pbs el- <br /> EMERGENCY/FIRE <br /> rEMERGENCY/FIRE NUMBERZ 2 7 ? Z ROAD NAME f � k44n � <br /> 7 .7 cs <br /> LEGAL DESCRIPTION(see tax receipt) <br /> CONTRACTOR <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION oma-' <br /> H r <br /> 0 <br /> o <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION v <br /> 0 0 <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; Commercial Business; Bedroom;Deck;etc.) <br /> 3 <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. In <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 3 <br /> T 7 rn <br /> Z C <br /> 1. All required dimensions or distances to be shown or drawn to scale. ?j o <br /> 2. Show the location and size of all existing buildings(EB) and all new buildings (NB) and indicate m y' lin <br /> North (N). w m <br /> 3. Show dimensions in feet of the following: (a) building(s)to all lot lines, (b) building(s)to centerline of m I <br /> road, (c) building(s) measurement to the ordinary high water mark(OHWM)of lake, stream or river. 4__ <br /> r <br /> 4. Show the location of the well (W), septic tank(ST)and drainfield (DF), and all distances to buildings, 0jZ <br /> roads, lake, lot lines. L <br /> 5. Indicate if a walkout basement is planned and show areas to be graded or filled. I I 1 1 <br /> 6. If separate plans are submitted by an architect, engineer, builder, contractor, etc., the plans must be U <br /> signed and dated by the owner. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BE- !� <br /> o <br /> FORE A PERMIT CAN BE ISSUED. <br /> 0 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONDITIONS OF PERMIT: o <br /> N <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 9 <br /> PERMITTED. ( _ <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC., ALLOWED WITHIN 75 FEET OF THE V <br /> OHWM OF LAKES, PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. v <br /> 5. <br /> F <br /> 6. <br /> 7. y o c �OO m <br /> w ni O L^Z <br /> 8. o f �Cn <br /> s cis : m <br /> O <br /> I declare that this application (Including any accompanying schedule) has been examined by me and to the best of my ` m <br /> knowledge and belief it is true, correct and complete. I acknowledge that 1 am responsible for the detail and accuracy of O <br /> all information contained in this application(Including any accompanying schedule)and I further declare that I recognize <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- <br /> o ; o : <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 p <br /> providing in this application. I agree toounty officials charged with administering county ordinances or othe <br /> authorized person to have access to a ova ascribed premises at any reasonable time for the purpose of Inspection. <br /> SIGN HERE <br /> N ; <br /> (signaturil of owner or building contractor) (date) o E f <br /> ZONING ADMINISTRATOR Im (y�q <br /> N+NN tnm"NN T <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o, P o p, v,N o m <br /> 00000000 <br /> 00000000fA <br />