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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administra r - o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> N O0 <br /> N <br /> 1 f d <br /> OWNER L/ ( �J^ TELEPHONE /�V?55 0 r� <br /> HOME ADDRESS Q u O �y��� ►�/ Yf f�✓1�6 ��SS�(og o 9v <br /> EMERGENCY/FIRE NUMBER / ROAD NAME <br /> LEGAL DESCRIPTION see tax receipt) <br /> n <br /> DWELLING/BUILDING X GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ CO 0 <br /> TYPE OF PERMIT(S): Q <br /> FILLING/GRADING ❑ CAMPING UNIT [ISUBDIVISION ❑ n' <br /> //`` ui <br /> STRUCTURE/ADDITION USE:4�fo ( " <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) Cn <br /> a <br /> BUILDING CONTRACTOR: <br /> v <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 0 1 <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m m 'o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). N o <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 v <br /> Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. ° <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 W <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> o ` <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN W O 1 <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT l <br /> ISSUANCE. A, <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. tIW <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RET ING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK EA. <br /> A V 0 � oC L <br /> CD <br /> 6. 3 C'N %e — ;U m C m . O O C <br /> Ul O fO <br /> 7. O H Co <br /> `� <br /> (n; m <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my [j 10 <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 1 further declare that I recognize m m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- v <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 l m <br /> providing in this a plication. I agree to permit county officials charged with administering county ordinances or other `W' m <br /> authorized perso to ave access to the ove described premises at any reasonable time for the purpose of inspection. my <br /> m : <br /> m : <br /> cn <br /> SIGN HERE �" ag — <br /> q <br /> (si ure or buil ng a (date) <br /> ZONING ADMINISTRATOR <br /> N NOINN01 fT <br /> (T OI 0 01 N O O <br /> 0 0 0 0 0 <br /> TOW SHIP PERMITS MAY BE REQUIRED 00 0 <br /> 000000 <br />