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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v 0 z <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> o <br /> N <br /> OWNER ��/1/►)A L1 !_/ TELEPHONE(7r5) ya—Z&H v <br /> � <br /> HOME ADDRESS <br /> &97 D/c/ 7z� t4g7_ <br /> CD <br /> 0 <br /> EMERGENCY/FIRE NUMBER �07g 7 ROAD NAME �/� 7< <br /> / iE 39L177L ' 1 <br /> LEGAL DESCRIPTION(see tax receipt) N 1 y <br /> I � <br /> DWELLING/BUILDING 1:1GARAGE/ACCESSORY STRUCTURE ADDITIOor <br /> PRIVY ❑ U) 0 <br /> TYPE OF PERMIT(S): a <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ c <br /> STRUCTURE/ADDITION USE: l�I11/11 CrCI�'t fJf I� / 0 1 <br /> ome/Cabin;�Co)mmercial Business; edroo , Deck; etc.) (nL <br /> BUILDING CONTRACTOR: S <br /> v <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR T 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O m <br /> " CL <br /> -nZ <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). C o <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO fH 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. m o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHENq o <br /> NEEDED. C G <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z ^ <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT �J,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 THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> 6. COD mcHmEL <br /> o ' 3 <br /> 7. <br /> o . <br /> = rn : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my Zj c ID <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of d <br /> all information contained in this application(including any acc p@�r ' g schedule)and I further declare that I recognize m m <br /> that this information I am providing will be relied upon by- t tt Wisconsin in determining whether to is- p <br /> sue a permit. I further accept all liability which may be a result tBurnett relying on this information I am m <br /> providing in this application. 1 agree to permit county officials charged wit jjd Itnistering county ordinances or other m E <br /> authorized pers o have access to the above described pre t n reasonable time for the purpose of inspection. T <br /> I C <br /> m : <br /> SIGN HERE 3 I to <br /> (signature of ne r bu Col,A'7-�� I (date) <br /> of <br /> ZONING ADMINISTRATOR r 1 �j— <br /> (n (T N N N rT <br /> (71 ut O ut VI O O <br /> TO SHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />