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(91/7 Gm-np <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 OZ <br /> APPLICATION FOR LAND USE PERMITS 3 ° <br /> N 0� <br /> 6s- <br /> (- <br /> /1 N <br /> OWNER TELEPHONE Z <br /> O <br /> OV <br /> HOME ADDRESS Z 1?Gti/ 1�� � � � ( �1- f <br /> «" ✓ <br /> o � <br /> EMERGENCY/FIRE NUMBER 3�7 t`A ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) / L3 V17 qe) 1L146 (/ I <br /> [ r CJ T CD <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE 1:1ADDITION ❑ PRIVY ❑ N o' <br /> TYPE OF PERMIT(S): c� <br /> FILLING/GRADING ❑ C-WPING UNIT El SUBDIVISION ❑ �-�. <br /> O)` \' / p N <br /> STRUCTURE/ADDITION USE: y 1!� o' <br /> (Home/Ca in; Commercial Business; Bedroom; Deck;etc.) N <br /> D ^ <br /> BUILDING CONTRACTOR: <br /> LJ <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n - <br /> M y <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p `D <br /> In o <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. Z <br /> n D, � <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m m <br /> NORTH(N). <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 <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 Q <br /> MUST BE SIGNED AND DATED BY THE OWNER. a <br /> o j <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. Z <br /> CONDITIONS OF PERMIT: ° <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT O <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 /> 6. C� i/ `C� <br /> - K � <br /> m � mmoma : m <br /> 6. m � 3cL2O °j ;a <br /> (D C (Nj, N O 3 <br /> 7. ZN (D O <br /> O T 4 <br /> _ Cnm 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 1 mm <br /> all information contained in this application(including any le and I further declare that I recognize t7 <br /> that this information I am providing will be relied upon bi/i u y f in etermining whether to is- O <br /> sue a permit. I further accept all liability which may be r f re ( on this information I am <br /> providing in this application. I agree to permit county ials charged wit ad in unty ordinances or other <br /> authorized person to have access to the above describe emises any a nable time r t e purpose of inspection. m <br /> m : <br /> CD <br /> SIGN HERE �7=-,- <br /> (signature of ow er building con ETT G+OU^�T� (date) <br /> ZONING ADMINISTRATOR COUNTY <br /> II <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />