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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator c, �Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r <br /> N � <br /> � {7� �/ C <br /> OWNER SA �� TELEPHONE <br /> CD <br /> HOME ADDRESS <br /> EMERGENCY/FIRE NUMBERROAD NAME �� �J, p�( l ~ Ze <br /> LEGAL DESCRIPTION(see tax receipt) <br /> 0 � <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ rp o <br /> TYPE OF PERMIT(S): Q ' <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ o' <br /> STRUCTURE/ADDITION USE: t�/�if'/�C� C aQ x y b l� <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) <br /> BUILDING CONTRACTOR: <br /> C <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n <br /> O <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O (D <br /> n a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. M O Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> m m <br /> NORTH(N). <br /> n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m B <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF 1Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. 1 o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO �I <br /> BUILDINGS, ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <br /> ) N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. �� t <br /> U` o o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a O <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 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 <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. ' This structure to be used as private residential A v r D o a o v <br /> 6. garage/storage onl . Not to be used for human 0 < 3 = 8 0 a m m <br /> Y m omxr = <br /> habitation. " C <br /> 7. o <br /> o CD <br /> = cn: A <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my G) C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of '� 2 rn <br /> all information contained in this application(including an accompanyingschedule and I further declare that I recognize Q <br /> PP (� 9 Y ) 9 Ob � t7 <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 m <br /> providing in this application. 1 agree to permit county officials harged with administering county ordinances or other <br /> authorized person to have acces the above described pyefinlos at any reasonable time for the purpose of inspection. `D <br /> -n <br /> (D <br /> SIGN HERE <br /> (signatur ozrn r or Iding co a tor) (date) <br /> ZONING ADMII RATOR <br /> �) n <br /> TOWNSHIP PERMITS MAY BE REQUIRED o?'3 7,) <br /> ,,213'2V G- <br />