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(31 <br /> Burnett Cwjnty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 G) Z <br /> APPLICATION FOR LAND USE PERMITS CD ° <br /> r <br /> OWNER , TELEPHONE se.— 'y 5-4� 0 <br /> v <br /> CD <br /> HOME ADDRESS <br /> 1" m <br /> EMERGENCY/FIRE NUMBER QJ 6 7 ROAD NAME/ <br /> LEGAL DESCRIPTION (see tax receipt) ��jA1 <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ rn <br /> TYPE OF PERMIT(S): I cQ <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ O n <br /> STRUCTURE/ADDITION USE: <br /> (Home/ in; Commercial Business; Bedroom; Deck; etc.) co <br /> -- <br /> BUILDING CONTRACTOR: 17 <br /> CDm <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 77 SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n <br /> ..._.._.____ ;Um \ <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p m <br /> -n a <br /> n Z <br /> 1. ALL RETIUIRED OtMEWONS-8RDISTANCES TO BE SHOWN OR DRAWN TO SCALE. <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> m o <br /> NORTH(N). C c> <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m <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 t <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 W <br /> MUST BE SIGNED AND DATED BY THE OWNER. _-Z 0 <br /> v � ) <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a <br /> NEEDED. Y ` <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z W <br /> CONDITIONS OF PERMIT: <br /> o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT \ <br /> ISSUANCE. I \ <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. \ 1 <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. i „ A p <br /> 5. <br /> I CD C y N O 53_ <br /> 7. Z : m o 1 <br /> O T <br /> - Cn : mA <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my C) c 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 <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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m : <br /> m : <br /> m : <br /> 111/ yy f �, <br /> SIGN HERE ����� ���74 �� ��^t]7C]� <br /> (signature of or building co itrac ) (date) Q <br /> ZONING ADMINISTRATOR <br /> TOWN HIP PERMITS MAY BE REQUIRED <br />