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% f <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator < o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> C (lpp /7 <br /> tln�( lur1Gl (a)oOGQ�5Iz``S CDJv <br /> ti ry <br /> n <br /> t / L n <br /> OWNER S f eUe n = (L(UO✓V mUb L i�rS Pl�j� TELEPHONE <br /> CD <br /> HOME ADDRESS �/ Dr � '�� r L'✓l/QM/itt, //JIt/ ���/� <br /> EMERGENCY/FIRE NUMBER ROAD NAME W11jw04)d <br /> 2 CSM <br /> �/ J /AOXj� lvwY 'D' 'D0 d- !o <br /> LEGAL DESCRIPTION(see tax receipt) 0 � CSm U 1 �/�Jl� b C(,(yl , 127 — d 0 <br /> —{ lam— J <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE I� ADDITION ❑ PRIW ❑ c 0 <br /> TYPE OF PERMIT(S): c <br /> a, <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION S. <br /> STRUCTURE/ADDITION USE: ° <br /> (Home/ bin; Commercial Business, Bedroom; Deck; etc.) m <br /> BUILDING CONTRACTOR: <br /> v <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEEI OF PAPER. ANY INCOMPLETE R m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. ��ahl ' # G ^� , : H <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) ���e l�'�� $. <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m d �'� <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE y C <br /> NORTH(N). ° <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 \ c <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. rV <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS 5, o <br /> MUST BE SIGNED AND DATED BY THE OWNER. o O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a S <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONDITIONS OF PERMIT: O <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ' ) <br /> ISSUANCE. \U <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. r Q) <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 /> CD CD <br /> 6. v m Cuss �' 3 <br /> o <br /> : <br /> 7. _to: i <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my i7� C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy ofn IF <br /> all Information contained in this application(including any accompanying schedule)and 1 further declare that I recognize m m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m <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 ? i <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 reasonable time for the purpose of inspection. 1 <br /> m <br /> f\SIGN HERE <br /> (signature of o er or uilding contractor) (date) <br /> 469 <br /> ZONING ADMINISTRATOR <br /> NNN V VI <br /> (T O V7 O O <br /> O O O O <br /> TO NSHIP PERMITS MAY BE REQUIRED O 00 <br />