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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o 0 <br /> APPLICATION FOR LAND USE PERMITS <br /> o <br /> I <br /> OWNER C I1Q h LGS Qa n d TELEPHONE / -�3S 7 p <br /> R� W� SkK, <br /> HOME ADDRESS �� 4 S U I ✓) r <br /> 0 <br /> EMERGENCY/FIRE NUMBERS ROAD NAME <br /> ]y <br /> LEGAL DESCRIPTION(see tax receipt) <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE JX ADDITION ❑ PRIW ❑ <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBQIVISION D� <br /> STRUCTURE/ADDITION USE: F t cn <br /> (Home/Cabin; Commerce Business, Bedroom, Deck,etc.) m <br /> 2. <br /> BUILDING CONTRACTOR: <br /> m <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR -n 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. ; c <br /> G <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) -n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES 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 m m <br /> m o <br /> N <br /> NORTH(N). m \� <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 Z <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. ) IV <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <br /> RCHITECT, ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS 2. <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN A <br /> o <br /> MUST BE SIGNED AND DATED BY THE OWNER. p 1 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN 0 ° <br /> NEEDED. W+ <br /> Z <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. ° <br /> CONDITIONS OF PERMIT: C> <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT (� <br /> ISSUANCE. C' <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY VV <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> 5. TBACKA. / Jr/Y,Q q, �J <br /> lbem <br /> 6. Z Ngo : � 'o =i <br /> o T C m <br /> 7. = r� <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 6 2 A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of RD m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize p <br /> pon by the County of Burnett Wisconsin in determining whether to is- <br /> that this information I am providing will be relied u <br /> sue apermit. 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. <br /> C? <br /> � m <br /> �yo t?� V <br /> SIGN HERE (date) <br /> (signature of o or building con tor) I <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED G <br />