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(7-n2" '`V <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -CD o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. SU <br /> r <br /> N w <br /> CD <br /> OWNER TELEPHONE <br /> HOME ADDRESS PZ <br /> r � <br /> S- ROAD NAME <br /> EMERGENCY/FIRE NUMBER 3 "73 <br /> LEGAL DESCRIPTION(see tax receipt) <br /> r� m <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ u! <br /> 0 <br /> O <br /> TYPE OF PERMIT(S): C <br /> FILLING/GRADING/❑ CAMPING UNIT ❑ .�SS.UBDIVISION El a <br /> STRUCTURE/ADDITION USE: <br /> T(Homed/C-a—bin; Commercial Bisiness; Bedroom; Deck; c7.) U <br /> BUILDING CONTRACTOR: e <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 o <br /> -nV <br /> 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(EIB) m)AND ALL NEW BUILDINGS(NB)AND INDICATE m n <br /> NORTH(N). <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 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 (W. . <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> v � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN a S <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: IN <br /> (� <br /> 1 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. Q <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 /> /�TBACKAREA. <br /> 5 A/ <br /> A � x <br /> y `1llY�hr .u1 �a <br /> zvc>= v�vv <br /> rn <br /> CDc(nyoS3 <br /> 7. Z • N m <br /> O : <br /> l cn m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of n c <br /> all information contained in this application mcludin <br /> pp (' y accompanying schedule)and I further declare that I recognize m m <br /> that this information I am providing will be relied up urnett Wisconsin in determining whether to is ? O <br /> sue a permit. I further accept all liability which may t bfil tt r lying on this information 1 am m <br /> providing in this application. I agree to permit cou I it i 's4r county ordinances or other m E <br /> authorized person to have access to the above descr premises at an�rea n i e fpr the purpose of inspection. m <br /> m : <br /> MAY Ay y -a/ 69 <br /> SIGN HERE � 1UV� <br /> (signature ner or building8 or (date) <br /> ZONING ADMINISTRATOR DlJ 0: <br /> �Cm' <br /> to'AN (n N N(n (n <br /> VnOpmoO <br /> TO NSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 <br />