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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator 4� <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> n <br /> OWNER y�' I/ �`.�e � �/� TELEPHONE <br /> HOME ADDRESS vL //l ) G'/ i) /��LL,F •� O <br /> iv �_� Iy ✓ / Ut � <br /> r � <br /> EMERGENCY/FIRE NUMBER p�C` ///n,�� / {ROAD NAME / / �� <br /> LEGAL DESCRIPTION (see tax receipt) r WV �I / �,� /� l!i( !/ 1�/ U) I <br /> vv W w E 7DITII ( m <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION PRIVY ❑ y o <br /> TYPE OF PERMIT(S): c � <br /> FILLING/GRADING ❑ CAMPING U T ❑ SUBDIVISION ❑ La: <br /> q� N <br /> STRUCTURE/ADDITION USE: .G�/r d0'YV(. ez,Ic o' <br /> (Home/Cabin; ommercial B iness; Bedroom; Deck; etc.) (n <br /> BUILDING CONTRACTOR: / <br /> m <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81AX 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n <br /> O <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 <br /> -n <br /> nZ <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. <br /> n m � <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). C n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m ` B <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. o <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. <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 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a o <br /> NEEDED. <br /> ci <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <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 THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> C d ° 0 M of m <br /> 6. CD 3 'a (D ;a <br /> C y w o <br /> 7. Z ; y (D <br /> o �:i� m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of <br /> - rn :my —` C) AC <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m 0 m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- CD 0 <br /> � <br /> sue a permit. I f her accept all liability which may be a result of the County of Burnett relying on this information I am <br /> providing in this a plication. I agree to permit county officials charged with administering county ordinances or other <br /> authorized perso o have access t abo a described premises at any reasonable time for the purpose of inspection. CD <br /> m <br /> m <br /> SIGN HERE <br /> 17 �Q <br /> (si nature of owner or buIng contractor) (date) <br /> ZONING ADMINISTRATOR Cjy <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> C <br />