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Burnett County 7410 Co. Rd.K, No. 102, Siren,WI 64872 Office of Zoning Administrator T a o <br /> APPLICATION FOR LAND USE PERMITS R <br /> c� n <br /> OWNER (.,,Ey pGC -�,- � TELEPHONE 5J6 � -.Z /! �� W v , <br /> G� v <br /> m <br /> HOME ADDRESSa O <br /> ' r m <br /> EMERGENCY/FIRE NUMBER ��Q C�� ROAD NAME �� / g <br /> �SJ <br /> LEGAL DESCRIPTION(see tax receipt)� �/ I X <br /> S i 3�J .tJ. /.Y C <br /> TYPE OF PERMIT(S): DWELLING/BUILDING_.-_GARAGE/ACCESSORY STRUCTURE�ADDITION N <br /> c <br /> c <br /> a <br /> 5. <br /> SANITARY PRIW FILLING/GRADING CAMPING UNIT SU DIVISION <br /> m <br /> STRUCTURE/ADDITION USE: _12 � ,42 j 7L/y JO F- d i <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR v <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. In I <br /> DIRECTIONS FOR PLOT PLAN DRAWING- (AERIAL OR TOP VIEW) M <br /> 0 <br /> I. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. T v Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m ar <br /> NORTH(N). a c t O <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m ✓ 0(3,9 <br /> M)OF LAKE, <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWUZ <br /> STREAM OR RIVER. i Z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- S <br /> INGS, ROADS, LAKE, LOT LINES. C� <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. I WW <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS 1 <br /> MUST BE SIGNED AND DATED BY THE OWNER. c __ <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE '" c <br /> ISSUED. g 0 I <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z .. <br /> CONDITIONS OF-PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT So <br /> C> <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 rt <br /> PERMITTED. V 1 <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 /> 6. z � �or, �iipo v <br /> Z : <br /> O <br /> —u!: .D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c ': i :' A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize CL m <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- E p <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this Information 1 am ' <br /> providing in this application. I agree to permit county officials charged with administering county ordinances Information <br /> other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of ior <br /> nspection. <br /> mE <br /> SIGN HER _ w <br /> ( at of ne building contras o / — <br /> (date) <br /> ZONING ADMINISTRATOR <br /> wwwww `+ <br /> .UNi N Cn,tNn,fNJI O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 <br />