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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o° o <br /> APPLICATION FOR LANND� USE PERMITS r� 3 � Z <br /> iiUlf iFi{ - lt)K, ����J 1 ; 0 y <br /> [ _ � v <br /> OWNER ALE 0. <br /> Q®, / 1NDF,gso /r' TELEPHONE7/S%��Q�d�i"�3 <br /> o <br /> m <br /> HOMEADDRESS !�l,�o /yj 1j#A40 &jjANrsBLW _ 4y/ j_y:R1j0 9 <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> c� �7 �p p I <br /> LEGAL DESCRIPTION(see tax receipt) N #4 Sitnl / T. ly , /� 15 <br /> e <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION v (�. <br /> a v <br /> S. <br /> w <br /> SANITARY X PRIVY FILLING/GRADING X CAMPING UNIT SUBDIVISION 0 i <br /> STRUCTURE/ADDITION USE: AB f gy-x36" COG (Ta 96 me►m 1AQ <br /> (Home/Cabin; Commercial Business;Bedroom; Deck;etc.) -0A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 o <br /> M Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 'q <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m n <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 m3 <br /> 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- J✓ <br /> INGS, ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. I o <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 /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED F ONSITE VERIFICATION BEFORE A PERMIT CAN BE Cr ° J <br /> ISSUED. }� <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. ✓✓ / �^ Jo <br /> CONDITIONS OF PERMIT: 7�f� p <br /> ( <br /> � <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS 60 DAYS OF PERMIT ���1 I 1 <br /> ISSUANCE. <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 <br /> fOFF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SP SPECIFICALLY <br /> 5 3136 q8 <br /> A 0 O: O <br /> 6. � <br /> ;w0 <br /> . M <br /> m <br /> I declare that this application (inkluding any accompanyin hedule) ha ben examined by me and to the best of my ? cq 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 m m E E m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determirdn t m C <br /> sue a permit. I further accept all liability which may be a result of the County of Bjrn 11 <br /> � n 'm E <br /> providing in this application. I agree to permit county officials charged <br /> with admo �n e E m E E <br /> authorized person to have access to the above described premises at any reasons � b8e o� pinspectl -n <br /> Qj� � <br /> SIGN HERE ®� ^' h <br /> (signatur of netIdl actor) Lj U <br /> �'T(date) -" <br /> ZONING ADMINISTRATOR "'- ' COUNTY <br /> . wwwwww� <br /> al CCA O fun (Nn 00 <br /> WNSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 0 0 <br />