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iO efty <br /> Burnett Countyr7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator d -0 o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> Q s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work y <br /> described and located as shown herein. The undersigned agrees that all work shall be done in actor- m <br /> dance with the requirements of the Burnett County Land Use Ordinance,Sanity ion Code,and with all other / <br /> applicable County Ordinances and the laws and regulations of the State of W sconsin. <br /> OWNERTELEPHONE <br /> I 1 d <br /> m <br /> HOME ADDRESS CC <br /> , III <br /> EMERGENCY/FIRE NUMBER ROAD NAME S <br /> J <br /> 1� <br /> LEGAL DESCRIPTION(see tax receipt) <br /> CONTRACTOR <br /> a 7 <br /> TYPE OF PERMIT(S): DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE ADDITION 0 -�-' <br /> \�(/ <br /> N <br /> SANITARY PRIVY FILLING/GRADINGZ� CAMPINGGLUUNIT SUBDIVISIONI_ <br /> STRUCTURE/ADDITION USE <br /> (Home/Cabin;Commercial Business; Bedroom; Deck;etc.) <br /> r <br /> 0 <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. r <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) O 3 <br /> T 'P N <br /> 1. All required dimensions or distances to be shown or drawn to scale. o n <br /> 2. Show the location and size of all existing buildings (EB) and all new buildin s(NB)and indicate m H: <br /> North (N). U) ° �✓, <br /> 3. Show dimensions in feet of the following: (a) building(s)to all lot lines, (b) building(s)to centerline of m 1� <br /> road, (c) building(s) measurement to the ordinary high water mark(01 of lake, stream or river. <br /> 4. Show the location of the well (W), septic tank (ST)and drainfield (DF), and all distances to buildings, / <br /> roads, lake, lot lines. Y�1 <br /> 5. Indicate if a walkout basement is planned and show areas to be graded or filled. �J <br /> 6. If separate plans are submitted by an architect, engineer, builder, contract r, etc., the plans must be a <br /> signed and dated by the owner. v <br /> R <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSI TE VERIFICATION BE- <br /> FORE A PERMIT CAN BE ISSUED. <br /> o <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: o <br /> N <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 130 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 p <br /> PERMITTED. N <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC., ALLOWED WITHIN 75 FEET OF THE <br /> OHWM OF LAKES, PONDS, RIVER UNLESS SPECIFICALLY PERMITTE . }}- <br /> 5. <br /> f <br /> 6. <br /> ronrnvm as y <br /> 7. n � g�L` P'—. m a In <br /> s m3. E e' C`Go3 <br /> Z f 0 TZ 1 <br /> 8. <br /> c�a m <br /> M <br /> I declare that this application (Including any accompanying schedule) has been examin d by me and to the best of my -- ' m <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsibla for the detail and accuracy of 92 ri p <br /> all information contained In this application(including any accompanying schedule)and further declare that I recognize o M 0 : <br /> � <br /> m o ! <br /> that this Information 1 am providing will be relied upon by the County of Burnett Wiscons n in determining whether to is- g : o <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett lying on this information I am p <br /> providing In this application. I agree to permit county officials charged with administer ng county ordinances or other 3 2 <br /> 3 : x : <br /> authorized person to have access to the above described premises at any reasonable tim for the purpose of inspection. m i <br /> m <br /> w i <br /> SIGN HERE N ': <br /> (signature of owner or building contractor) (date) o <br /> ZONING ADMINISTRATOR <br /> N N N N N N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o m <br /> 000 $ gSoom <br />