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enowlo <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 c) Z <br /> APPLICATION FOR LAND USE PERMITS _3 ° <br /> r <br /> H O <br /> q '7 c <br /> OWNER DO.0.4 �Y <br /> L /�/ 7it 41- <br /> TELEPHONE/�y�Syt'/—'7'3(3 p <br /> HOME ADDRESS �O 11�/dlle,y /C. Q% i f lE j� �^ ff / i ,/ !O� <br /> w tJ N ,1 !i(J r e <br /> EMERGENCY/FIRE NUMBER cS',11,;WF ,M ROAD NAME I o <br /> LEGAL DESCRIPTION(see tax receipt)L0T 6y / <br /> aU OT�J ) <br /> m <br /> 0 <br /> DWELLING/BUILDING 0 GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ o) o <br /> TYPE OF PERMIT(S): a <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ S BDIVISION ❑ <br /> Cr <br /> H <br /> STRUCTURE/ADDITION USE: J/.2.r <br /> �/ (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) v N <br /> BUILDING CONTRACTOR: t\ ,4FL-� C <br /> •o <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. In - <br /> 0y <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p � <br /> T <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> m <br /> NORTH(N). C <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. Q CJ► o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO I" 1 <br /> BUILDINGS,ROADS,LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> o � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q o <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o 1 <br /> CONDITIONS OF PERMIT: ! l( cu <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 SETBACK AREAS, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED W T <br /> 5. S,fie- I PoP <br /> m <br /> r [ m <br /> I declare that this application (including any accompanying schedule) has been examined-6y me and to the best of my G) 10 <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a) c <br /> Er <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m m <br /> that this information I am providing will be relied upon by the C rnett Wisconsin in determining whether to is- oO O <br /> sue a permit. I further accept all liability which may be a resuloMdi <br /> relying on this information I am m <br /> providing in this application. I agree to permit county offici � r ounty ordinances or otherauthorized person to have access to the above described pr ses at any e purpose of inspection. m <br /> CD <br /> � mE <br /> ' HERE �NlN �1 .?40 00G? <br /> (s' at re of own r wilding cont r) (date) 9 ) <br /> OMINISTRATOR URNETT <br /> NIN to ��A4, <br /> G N N t n N N (n [n <br /> N Un Otop OO <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />