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p Z <br /> Bt+rneft County 7410 Co. Rd.K, No. 102, Siren,WI 54872 Office of Zoning Administrator 3 0 0 <br /> APPLICATION FOR LAND USE PER I <br /> 0 o <br /> 1� <br /> 2 n,1 —�Ibq <br /> 1217L� ,VI \t ��f" FI 1 TELEPHONE t 7 ri <br /> OWNER <br /> 0 <br /> HOMEADDRESS I� �Lll� J,\ann � V, Dr X11 V-Ph w 7Z <br /> 1 m <br /> EMERGENCY/FIRE NUMBER ROAD NAME j,( 1A ( IAA <br /> LEGAL DESCRIPTION (see tax receipt) rOl nsk P SOG Rn—vv,—e `� YO�Ce1�C�J Wit '�(� rfDi <br /> �) o <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE 9 ADDITION LJ PRIVY LJa <br /> Cr <br /> TYPE OF PERMIT(S): o A <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ S. <br /> N <br /> O <br /> STRUCTURE/ADDITION USE: to <br /> ( ome/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> `tee <br /> 1� <br /> m <br /> BUILDING CONTRACTOR: <br /> 3 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/1 X 11 SHEET OF PAPER. ANY INCOMPLETE OR O 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. ;a m �� <br /> C (v <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIE" "nn CL z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 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). m 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF oZ <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 <br /> BUILDINGS,ROADS,LAKE, LOT LINES. N <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. O <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS 2. <br /> C I <br /> MUST BE SIGNED AND DATED BY THE OWNER. p c\ <br /> W ° <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN ,�U <br /> NEEDED. N <br /> Z <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: I O <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT �\ <br /> ISSUANCE. <br /> 2. REMOVAL OR ING OF TREES AND ALTERATIONS <br /> (— 1 <br /> 3. NO GRADING OR HORELAND A TERATIONS ARE AILLOWED UNLESS SPECIFICALIS RESTRICTED ALONG LY <br /> LINE. _ <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN THE REQUIRED WATER \aJ <br /> TBAC�AR /� L/ <br /> 5. 017 eeG �rS`�oTje- On[y G/191eSe]7a4G� A ,�, d i 0 0 m <br /> // // / lr 3nib —ea .0 <br /> 6. A1V'/: S /vim / � /, I�ry ���/2/�q�(CL4 I"� �1 .i y � N c 3 <br /> 7. <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> IS <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of m m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize C <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- <br /> sue apermit. I further accept all liability which may be a result of the County of Burnett relying on this information 1 am m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized pers a access above described premises at any reasonable time for the purpose of inspection. m <br /> m : <br /> `.. — <br /> SIGN HERE (date [ <br /> (signet a of nor or b I g cony ctor <br /> 40 <br /> en ul <br /> ZONING ADMINISTRATOR NO <br /> N0N0I0 <br /> ul <br /> V0 opN 0 0 0 0 0 0 <br /> TOWNSHIP ERMITS MAY BE REQUIRED 000 0 <br />