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Burnett Courtly 7410 Co. Rd. K, No. 102,Siren,WI 54872 Office of Zoning Administrator v-0 �o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> 9 <br /> OWNERMiFOV� %/&A'\ , e ICI TELEPHONE-7 l —ao1y1 G <br /> OR Y0. t1 <br /> m <br /> S <br /> HOME ADDRESS aa.�10 �p{7p 12 FTM It, fZJ ,—Sr, l �MNr SS� I ri r <br /> EMERGENCY/FIRE NUMBER ROAD NAME 1at$ .. <br /> v. <br /> LEGAL DESCRIPTION(see tax receipt) �� a CSM to 7 CA <br /> CA <br /> CA <br /> TYPE OF PERMIT(S):DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION cr — <br /> 5. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> ,j <br /> w <br /> ?— <br /> STRUCTURE/ADDITION USE: 3 FX�u R-ofl� Crtg I r\ — � sro t?_ <br /> �n <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR a <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T <br /> z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. mS 'A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m n <br /> NORTH(N). fn <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m v <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> STREAM OR RIVER. 0 <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 W <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE `" o <br /> ISSUED. `» <br /> CJ <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o Q <br /> CONDITIONS OF PERMIT: <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 STRUCTURES,INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN 75 FEET OF THE OHWM OF LAKES, <br /> PONDS,RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> pekmr i /8�1�— Sf�I .5 3 0. �H9019 <br /> Ir <br /> _ <br /> m <br /> I declare that this application (including any accofnpanying schedule) has been examined by me and to the best of my i a <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize o m m <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- Z <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 <br /> providing in this application. I agree to permit county officials charged with admini � Fer4nees�f["btfle m <br /> authorized person to have access to the above described premises at any reasonable eu�Fios�e of Inspection.'. T , E <br /> m i <br /> �- <br /> /y� N i t <br /> SIGN HERE 5 µ' /i✓i� <br /> (signature of owner or building contractor) )0 <br /> ZONING ADMINISTRATOR <br /> HHah� <br /> U - �- • NNtl1NN N <br /> V7 N O Vt tit O <br /> TOWNSHIP PERMITS MAY BE REQUIRE 0 0 0 0 0 0 <br /> UW SST u-'-))--6)_ <br />