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oyl m?'-p <br /> Burnett County 7410 Co. Rd.K, No. 102,Siren,WI 54872 Office of Zoning Administrator - c o <br /> APPLICATION FOR LAND USE PERMITS <br /> OWNER �(L( no h d® 11A S OIA TELEPHONE 77' ^epi �- <br /> IL <br /> HOME ADDRESS (fJ� �-6iyAj _�l t � P/I 5 /0 f AlJ�1 <br /> 0 $ <br /> EMERGENCY/FIRE NUMBER N q,30-5- ROAD NAME ao <br /> "'t 711--5 /�c /y rwsn yo A' R:7p z <br /> LEGAL DESCRIPTION(see tax receipt) v f 1--63 Cp rt �t �l� <br /> o <br /> 7 <br /> z9� <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTUREADDITION a <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> N � <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) $v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR T 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 a <br /> c C9 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) <br /> -n G 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 u <br /> NORTH(N). in <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 LAKE, Z <br /> 0 <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. 00 <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 64 1 <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS c <br /> MUST BE SIGNED AND DATED BY THE OWNER. 2 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> ISSUED. C? <br /> Z <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. P <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. <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. e� <br /> 5. 3 0EDM <br /> 6 <br /> 6. 00 ='o <br /> Z : <br /> 7. cin; i <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ; e5 ' C <br /> knowledge and belief it is true,correct and complete. 1 acknowledge that I am responsible for the detail and accuracy of n <br /> all Information contained in this application(including any accompanying schedule)and I further declare that I recognize <br /> es : 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 d <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person t ave access to the a o e de cribed premises at any reasonable time for the purpose of inspection. -n <br /> i <br /> SIGN HERE <br /> ( not roof er oPb Ing contractor) (date) <br /> ZONING ADMINISTRATOR 40 W40"W in� <br /> N NcnN N L"to <br /> I71 V104�N 00 <br /> 0 000000 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />