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Burnett CL•unty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - c o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> N � <br /> OWNERU l TELEPHONE /�ygg sa o <br /> / O <br /> HOME ADDRESS n 7{ <br /> _l r <br /> EMERGENCY/FIRE NUMBER ROAD NAME �l 'F `I (_Q <br /> LEGAL DESCRIPTION(see tax receipt) ' c <br /> DWELLING/BUILDINGet�I GARAGE/IA`CCECESSORY STR CTUR ADDITIIO\N ❑ PRIVY ❑ 0 <br /> TYPE OF PERMIT(S): ��77(( <br /> FILLING/GRADING Ll CAMPIN UNIT EI SUBDIVI ION ❑ <br /> N T�7 <br /> STRUCTURE/ADDITION USE: <br /> 0 <br /> o'm1/Ca in; Commercci I Business; Bedroom; Deck; etc.) <br /> BUILDING CONTRACTOR: I fir QA <br /> D' <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81A X 11 SHEET OF PAPER. ANY INCOMPLETE OR � <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 a <br /> � Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m a <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m n <br /> NORTH(N). q 3 <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. <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. <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS 2 <br /> MUST BE SIGNED AND DATED BY THE OWNER. 1 c <br /> � o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN a <br /> NEEDED. Q <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. d O <br /> CONDITIONS OF PERMIT: ((�� � <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT 'V <br /> ISSUANCE. L <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. ` �f� ,,// <br /> 5. fL_ !/L°�7T1 „tel .,LJ /'y/����1 //�, 3 r <br /> Q�(i of O C ! DfI W /�� � � n r 0, m <br /> l � � d ' m m <br /> 6. am `sem= .� <br /> N C H w o g <br /> 'riles /� lV� o � '< <br /> 7. <br /> — w ; [ m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my (j c C <br /> knowledge and belief it is true, correct and complete. I acknowledge that 1 am responsible for the detail and accuracy of n <br /> all information contained in this application(including any accompanying schedule)and 1 further declare that I recognize <br /> � M m <br /> that this information I am providing will be relied upon by the County of Bu�r1���//sdonsin in ermining whether to Is O <br /> sue a permit. I further accept all liability which may be a result of the CounW'o hi4ttrelyin�olt_this information I am m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other m <br /> authorized person to have access to the above described premises at any reas time-f purpose of inspection. m ': <br /> m : <br /> USM : <br /> SIGN HERE i <br /> (signature of owner or building t c fe. (da e) <br /> ZONING ADMINISTRATORI+fel <br /> 114 <br /> cn cn f»f»to <br /> N NIl1 NN N(T <br /> (T fTOfT 611 OO <br /> TOWNSHIP PER ITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0000000 <br />