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Burnett County 7410 Co. Rd.K, No. 102,Siren,WI 54872 Office of Zoning Administrator 0 o <br /> APPLICATION FOR LAND USE PERMITS <br /> w <br /> N <br /> OWNER <br /> o4 <br /> d Q9, /�,p a TELEPHONE ►��.5'��+ ✓G — 7®�7 p <br /> X:)oa, ry,V B// 0 <br /> HOME ADDRESS 'flyelalliq AW 10 /cam c <br /> ROAD NAME r vc �u 1 <br /> EMERGENCY/FIRE NUMBER 1 I IVB✓ - G7 P 1n�1 <br /> LEGAL DESCRIPTION(see tax receipt) �� rn�( N C S rt y�� - l!r °�/ 2 <br /> C <br /> TYPE OF PERMIT(S):DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION n <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 r <br /> of <br /> �,�. 111 , �11�rc <br /> STRUCTURE/ADDITION USE: �- �� 3.1I o <br /> (Home/Cabin; mmercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR r 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. ja <br /> ja <br /> 0 w <br /> c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) -n c <br /> M ^= AZ <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m O <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C c <br /> NORTH(N). H <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO v <br /> m <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. <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS J� c <br /> MUST BE SIGNED AND DATED BY THE OWNER. v <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE g 111 <br /> ISSUED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> P <br /> CONDITIONS OF PERMIT: �7 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT J <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. m an d p�p L m <br /> 2' 4 3 n3Fe9s <br /> 6. <br /> Z : '• i M <br /> 7. = r : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ZS c • c <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of ' CL M <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m <br /> that this information I am providing will be railed upon by the County of Burnett Wisconsin in determining whether to is- m <br /> € € v <br /> sue a permit. I further accept ail liability which may be a result of the County of Burnett relying on this information I am <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. - <br /> a , <br /> X10- 97 <br /> SIGN HER (date) <br /> (signature of owner or buildin*conr7L <br /> 1(a . H <br /> ZONING ADMINISTRATOR v 'm l) �^N`q�d'v' <br /> N N V1NN fnN <br /> (7i VtO(T toOO <br /> O 0 0 0 0 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 1'kke Se'(-T -as-Cj� <br />