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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 <br /> Office of Zoning Administrator .- o <br /> APPLICATION FOR LAND US PERMITS <br /> M o <br /> cTEr-t=Rw y A LB Rect+T q �q a q � � y 9j <br /> OWNER -$Keci+T ff/4VI(/L/ �j ''pee s�(`}1'Ip TELEPHONE (?53' 2S-I <br /> HOME ADDRESS 'LZQ�rJ M44- TUI�J`xsNl (Z , � G) k11 s'F�63? CD <br /> v \e : <br /> oi <br /> CD <br /> EMERGENCY/FIRE NUMBER 22�'{b / �/Z�� ROAD NAME (TOhNSOAJ I 0 <br /> 'TA,x PARc.el_ o-7 -01b 2-38'(s_3S-n ozlvo <br /> LEGAL DESCRIPTION (see tax receipt) C5 m <br /> V 2 ( V L-VTS <br /> CID <br /> TYPE OF PERMIT(S); DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ d 0 <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ a <br /> STRUCTURE/ADDITION USE (lALI GtG/Ca Q m <br /> o <br /> (Hobin, Commercial Business, Bedroom; Deck;etc.) ' <br /> BUILDING CONTRACTOR: m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 3. <br /> m <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SOWN OR DRAWN TO SCALE. <br /> -n <br /> F) o n (� <br /> 2. SHOW HE LOCATION AND SIZE OF ALL EXISTING BUILD NGS(EB)AND ALL N W BUILDINGS(NB)AND INDICATE m 0 <br /> �Z <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF 0 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. 1 Z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO o <br /> BUILDINGS,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 0 \ <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> lj� I <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN o <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONDITIONS OF PERMIT: Z <br /> o � <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. I <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> fhis structure to be used as private residential <br /> 6. garage/storage only. Not to be used for human m m W A � a m O v o m o n F m m <br /> habitation. Co a a a <br /> �. '6 N C y N O <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o �j N O <br /> knowledge and belief it is true, correct and complete. I acknowledg at I am responsible for the detail and accuracy of G n C <br /> all information contained in this application(including any accomp i e le)and I further declare that I recognize m ` m <br /> that this information I am providing will be relied upon by the Cou m m <br /> sue a permit. I further accept all liability which may be a result of in in determining whether to is- <br /> n this information I am d <br /> providing in this application. I agree to permit county officials c ed with <br /> authorized person to a access to th above described pre is any r asonable till en t r nances or other ° <br /> of inspection. `D <br /> N <br /> SIGN HERE CD <br /> ig lure o orbuildin ntractor) date) D i <br /> ZONING ADMINIST ATOR C CDU JCJ <br /> Nit 17)f <br /> TOWNSHIP PERMITS MAY BE REQUIRED I CI g3 <br />