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onI <br /> Burnett County 7410 Co. Rd. K, No. 102,Siren,WI 54872 Office of Zoning Administrator -Uogt f <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N 0 <br /> OWNER ^ TELEPHONE <br /> HOME ADDRESS yg�7- /y9'"ej 1.0D t)aw /777, ®� <br /> I <br /> EMERGENCY/FIRE NUMBER 1-2 ROAD NAME ��n�/ Lk ;Pd <br /> LEGAL DESCRIPTION(see tax receipt) Lo f- �S/r1 VQ L jq a5�2 y_yp_/br `� W <br /> Cl) 0 <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE /+DDITIONX__ n <br /> LA <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION <br /> rn <br /> m <br /> / �/ <br /> STRUCTURE/ADDITION USE: I6Xo2� L i✓'/14 Q 1rY V) <br /> (Home/Cabin;Commercial Business;Bedroom; Deck;etc.) v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 H <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE _ <br /> NORTH(N). U) O <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. ° <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 S' <br /> MUST BE SIGNED AND DATED BY THE OWNER. ° <br /> o � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> ISSUED. IIryJ <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o ?t QjI I <br /> CONDITIONS OF PERMIT: (I 1 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ` r-tW <br /> ISSUANCE. 0 <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 'a 0 <br /> 6. a oo' <br /> ON O O m <br /> O <br /> �I M7. _ <br /> = y: : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my IG3 C <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 ' <br /> G <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m <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 m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other o <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m i <br /> (D : <br /> m : <br /> SIGN HERE <br /> y �Q � <br /> n ure of owne,91 uilding contractor) date) <br /> ZONING ADMINISTRATOR . . . . <br /> H 9 <br /> 69HNN <br /> N " M N CA <br /> e��z R V• POP OO <br /> O O O OO O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0000 0 0 <br />