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6-�C'Z-yr� <br /> 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 /> N � <br /> H <br /> OWNERR L R )vl E y RS G J�/ TELEPHONE / Z -7 <br /> V1 <br /> HOME ADDRESS ) p 3-7 J 8/S ST lvl d,J e o o il /?HP1103 !t'/'i <br /> m <br /> EMERGENCY/FIRE NUMBER / i�FE p ROAD NAME S T R <br /> i•o 7- /5` A4.1--d OF Lv A/P �-.S A"7 fl RE X1 <br /> LEGAL DESCRIPTION (see tax receipt) S U!S c+ Ej v/ T •[&f-S 5o� /y De:w�V1 "' a <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE W ADDITION ❑ PRIVY ' c 0 <br /> TYPE OF PERMIT(S): ❑ <br /> FILLING/GRADING ❑ CAMPING UNIT ElSUBDIVI N JS <br /> N <br /> STRUCTURE/ADDITION USE: S Ri &F- S e fl B//d ed <br /> (Home/Cabi , t;ommer I s/in s; Bedroom; Deck;etc.) (n <br /> BUILDING CONTRACTOR: S rc LF W i�� <br /> VLjCD <br /> 5i <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR -n 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> x y CSC <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) -n m <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 'A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <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 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 O <br /> BUILDINGS,ROADS,LAKE,LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. fV C <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. to <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q <br /> NEEDED. 2 C <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 <br /> ISSUANCE. w <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 THE REQUIRED WATER <br /> SETBACK AREA. [J�` �� v <br /> 5. -- be n ,nSldc o� d Ssur� JA/s�hGe re • //P T/le �e z ' 0 r. L a m <br /> �� Mo <br /> 6. /.Vl(C aesi1L Q�res. /'� SS/ e( �j"/'«� e^7rf�- y o N g S 3 <br /> J c q Z : " mom i <br /> I declare that this a plication (including any accompanying schedule) has been examined by md and to the best of my G)c c <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of o <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize �/\ m p <br /> M <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 0: O <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 E m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> CD : <br /> m : <br /> SIGN HERE <br /> (signatureofb er r bui i c (date) <br /> ZONING ADMINISTRATOR CS <br /> CCA O O <br /> TOW SHIP PERMITS MAY BE REQUIRED c <br />