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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> N � <br /> N <br /> C <br /> OWNER TELEPHONE <br /> TELEPHONE Gc (� 35�o�3s o <br /> JJr�� <br /> ` M d <br /> HOME ADDRESS S`1 't ��'i ocxC ,,t\ ! 'V�✓I 1 p/J LD �S p�q v r <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) b 1 � / �P S Q,�� CD <br /> DWELLING/BUILDING ElGARAGE/ACCESSORY STRUCTURE El ADDITION ❑ PRIVY (nor O� <br /> TYPE OF PERMIT(S): I c <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ <br /> mCL <br /> STRUCTURE/ADDITION USE: /Ion <br /> (Home/Cabin; CoYhmercial Business; Bedroom; Deck;etc.) m <br /> BUILDING CONTRACTOR: <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'/:X 11 SHEET OF PAPER. ANY INCOMPLETE ORm 3Its <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. p <br /> ,ZI N C) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <br /> T Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <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 '3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF i1— 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 /> S. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. l i <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. <br /> 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q\ <br /> NEEDED. (pl <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c (� <br /> CONDITIONS OF PERMIT: (� <br /> I <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT C7 <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 t <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> ��S,...aaETBACK AREA. <br /> 5. l 5lC/KS -5 n _ 0 O 'C <br /> 6. m v CL CD y <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of myc C <br /> Q <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 I recognize <br /> " c" m <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. I agree to permit county officials charged with administering county ordinances or other m <br /> authorized person to have access to the above ribed premises at any reasonable time for the purpose of inspection. -n <br /> CD : <br /> CD <br /> mss_ rD <br /> SIGN HERE cam`' " <br /> (signature of o r or building con ctor) (date) <br /> ZONING ADMINISTRATOR <br /> N NIN) NL" M <br /> V7 O u• f71 O O <br /> TO SHIP PERMITS MAY BE REQUIRED o 0 0 0 0 0 <br /> 0 00000 <br />