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aw c-" <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v ci Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N 0 <br /> C <br /> N <br /> OWNERC t1 TELEPHONE <br /> d S�_ Gj3� .S351f v <br /> m <br /> HOME ADDRESS Zo s�%74&y,,f-d Ad!' �WC Ui[Lr 5,5113 v 9 <br /> gm 7) <br /> EMERGENCY/FIRE NUMBER 14 ROAD NAME ,�'L�iS JO/Z i✓ e.- <br /> LEGAL <br /> LEGAL DESCRIPTION (see tax receipt) <br /> a(� — yp / Ywc m <br /> �( 0M. <br /> DWELLING/BUILDING .I/J GARAGE/ACCESSORY STRUCTURE ❑ ADDITION El PRIVY ❑ <br /> TYPE OF PERMIT(S): co <br /> v <br /> FILLING/GRADING ❑ CAMPING U IT ❑ SUBDIVISION ❑ c <br /> /y N <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) m p <br /> BUILDING CONTRACTOR: A)Ua TA11-t..(p 1324 /5 <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE ORIn <br /> 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> N C <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O c <br /> In 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(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 3 <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. P <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHENq o <br /> NEEDED. C7 <br /> 1 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o C <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE `�• q <br /> - r a <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> m : m m W U q <br /> 6. i 3 a Q j <br /> R; <br /> 7. c j " � ID <br /> r- i—Cn m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my G3 c c <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of c <br /> all information contained in this application(including any accompanying schedule)and I further declare that Irecognize ;am m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Is y O <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 m ; <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other to <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of Inspection. T <br /> m : <br /> c, m <br /> SIGN HERE 3 �/ J � '• <br /> roQ <br /> (signature o'f�owner orr building contractor) (date) <br /> ZONING ADMINISTRATOR —CT)m 1 I 1 jcfiDAQw_ <br /> N N(�71 NN U1N <br /> fT N O N N O O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />