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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> N O <br /> N <br /> C <br /> N <br /> 1 Q 1 4 <br /> OWNER Rn b�f-C S1 [ Y bt`�D d^►tSG+t TELEPHONE <br /> p �/ / J Q <br /> HOME ADDRESS aQ��T &.J;ljkw(.� �QIt� U ruf ��� dSyg,�D <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER a g.Q_l 7 ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) tC� L5-c S`'yl t' l �,(� O�a -q-6 -/� n Lf m iZ <br /> {{ -Z o <br /> DWELLING/BUILDING 1:1GARAGE/ACCESSORY STRUCTURE XL, ADDITION ❑ PRIVY ❑ m o <br /> TYPE OF PERMIT(S): ID rr <br /> FILLING/GRADING El CAMPING UNIT ❑ SUBDIVISION ElN <br /> STRUCTURE/ADDITION USE: &Lk-Q 1e Aa X 2a 0 <br /> Home/Cabin; Commercial Business; Bedroom;Deck;etc.) m O <br /> BUILDING CONTRACTOR: L©Wt <br /> v <br /> m <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. p Q <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) �Kv 0 o <br /> S <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n m 33 <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). y <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 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. C <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 U1 <br /> MUST BE SIGNED AND DATED BY THE OWNER. ,o C <br /> 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHENq S <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. 0 O <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. I /, <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY IW'•. W <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER O <br /> SETBACK AREA. <br /> 5. <br /> CD o. m � m m <br /> 6. RL m Cuyo N 3 <br /> U1 (00 =1c q <br /> 7. o ;a <br /> i_0) : i € m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c3c ID <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of m L' <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognizeCL <br /> m : m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- <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 administering county ordinances or other m <br /> authorized person to have access to jAe above dqVqrIbed premises at any reasonable time for the purpose of inspection. -n <br /> CD <br /> CD : <br /> 4a <br /> SIGN HERE .S 2 <br /> nature o ner or building contractor) (d te) <br /> ZONING ADMINISTRATOR <br /> �N01NK)C"En <br /> N NNNNtn ui <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />