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.K <br /> Burnett County 7410 Co. Rd. K, No. 102,Siren,WI 54872 Office of Zoning Administrator w " 0 0 <br /> APPLICATION FOR LAND USE PERMITS 3' <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for thwork <br /> described and located as shown herein. The undersigned agrees that all work shall be done in ccor- g lrt <br /> dance with the requirements of the Burnett County Land Use Ordinance,Sanitation Code,and with all other o Ql� <br /> applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> I v <br /> OWNER l �S j / TELEPHONE <br /> HOME ADDRESS <br /> EMERGENCY/FIRE NUMBER 17 ROAD NAME A2, <br /> LEGAL DESCRIPTION(see tax receipt) <br /> CONTRACTOR o <br /> TYPE OF PERMIT(S):DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE ADDITION m r <br /> o <br /> 0 <br /> SANITARY—PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION <br /> o $ <br /> STRUCTURE/ADDITION USE: —5,,4 <br /> (Home/Cabin;Commercial Business, Bedroom;Deck;etc.) <br /> 0 <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n <br /> A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) O 3 v <br /> TZ <br /> 1. All required dimensions or distances to be shown or drawn to scale. FL <br /> m P <br /> 2. Show the location and size of all existing buildings(EB)and all new buildings (NB) and indicate C © o <br /> North (N). y I <br /> 3. Show dimensions in feet of the following: (a) building(s) to all lot lines, (b) building(s)to centerline of m <br /> road, (c) building(s) measurement to the ordinary high water mark(OHWM)of lake, stream or river. <br /> 4. Show the location of the well(W), septic tank(ST) and drainfield (DF), and all distances to buildings, \ <br /> roads, lake, lot lines. t <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 must be W a <br /> signed and dated by the owner. i Cn <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION E- n <br /> FORE A PERMIT CAN BE ISSUED. <br /> 2. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. S G <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERM T <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 a D <br /> PERMITTED. 1 <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC., ALLOWED WITHIN 75 FEET OF THE � <br /> OHWM OF LAKES, PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> 6. <br /> f m <br /> 7. �g � co9 <br /> vom 3 <br /> 5' i L°Q <br /> o — <br /> C <br /> 1 declare that this application (Including any accompanying schedule) has been examined by me and to the b Ist of my m <br /> knowledge and belief It is true, correct and complete. I acknowledge that I am responsible for the detail and ac ;uracy of <br /> om o : <br /> all information contained In this application(Including any accompanying schedule)and I further declare that I cognize o�^ b E <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin In determining who ier to Is. 0 . o <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this Informi don I am IU�'*� [ 0 E o'. <br /> providing In this application. I agree to permit county officials charged with administering county ordinance or other ?t E 3 <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of in pection. m !' <br /> SIGN HERE <br /> (signature of own or buil g ctor) /(data i o <br /> ZONING ADMINISTRATOR <br /> m <br /> T NSHIP PERMITS MAY BE REQUIREDo o o mo o m <br /> ooSS000N <br />