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Burpett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator a 0 " o <br /> APPLICATION FOR LAND USE PERMITS . <br /> 0 <br /> OWNER ( Q ( 7 (/ //flap n A JCl-L- TELEPHONE 5o 1 Q(1 t _ 3 $6y m <br /> HOME ADDRESSz4z W6614 u" CtJ /i/�1t/ — ',Cih L^i�� g", S'5'li©: <br /> 7� �lz k� �0 <br /> EMERGENCY/FIRE NUMBER ROAD NAME Rn,,fd <br /> �a t <br /> LEGAL DESCRIPTION(see tax receipt) �(�-� �— ��- r <br /> e: <br /> !A � <br /> TYPE OF PERMIT(S): DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE X,—ADDITION c <br /> a <br /> 5. _n <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION o <br /> d <br /> STRUCTURE/ADDITION USE: CL_R A 6'-C 9 <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) ' <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR In 3 (�}I- <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> 0 a <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 <br /> O Z <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 C n <br /> NORTH(N). y o <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO nl 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. 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. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE q U? <br /> ISSUED. 2 V 1 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: C�} <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT rt ' Uj <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. l/ <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. qpRg <br /> td 3 n/d SIM <br /> 6. C�"" o 3 <br /> 7. o i z <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c i ; C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of m <br /> all information contained in this application(including an accompanyingschedule and I further declare that I recognize <br /> B <br /> PP ( 9 Y ) 9 E m <br /> that this Information 1 am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- m 0 <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 om <br /> authorized person to have access to the above described premises at any reasonable Amp for t p purposef Im <br /> SIGN HERE i <br /> (sigma re of owner or building contractor) (date) <br /> ZONING DMINISTRATOR F 10f)f ( " <br /> 40'w 49 <br /> irfmov�,Poo <br /> --- - <br /> Ca 00000 <br /> TOWNSHIP PERMITS MAY BE REQUIRE" 0 0 0 0 0 0 <br /> �'� kbitlid L4Ke- eco-, Da,-tbu4% <br />