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cgZ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 0Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r <br /> N O <br /> N <br /> CD <br /> C <br /> OWNER � C�-� TELEPHONE 6-4—� 39– �19CD <br /> n <br /> HOME ADDRESS <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER 1 � ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) 1 �� L7,o ' l� cn <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ N Cn o <br /> TYPE OF PERMIT(S): (� � <br /> o- <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION J �,[/ // <' <br /> STRUCTURE/ADDITION USE: Cil �/ P/!� �`f y 0 <br /> (Home/Cabin; Commercial Busin as; Bedroom; Deck;etc. <br /> BUILDING CONTRACTOR: (AJ W�i� �� � �7� m' 1 <br /> T' D <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'h X 11 SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T <br /> O <br /> ;a N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O m <br /> -n <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m a <br /> NORTH(N). y o <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m \ <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. o <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 0 O <br /> MUST BE SIGNED AND DATED BY THE OWNER. F 1 <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z N <br /> CONDITIONS OF PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT N <br /> ISSUANCE. ) <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. OC <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 V <br /> SETBACK AREA. <br /> 5. <br /> m V m 0,0 0O o f m <br /> T C <br /> =CD 0 <br /> rn : AI declare that this application (including any accompanying schedule) has been examined by me and to the best of my c <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of n 2 <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognizeCD <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 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 <br /> providing in this application. 1 agree to permit county officials charged with administering county ordinances or other <br /> CD <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> fD <br /> N <br /> SIGN HERE <br /> (signature of owner or building contractor) t (date) U:I <br /> ZONING ADMINISTRATOR <br /> � a? <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />