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0�cnlApj <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v 0 Z <br /> APPLICATION FOR LAND USE PERMITS I <br /> 0 <br /> OWNER e7 j)�� TELEPHONE <br /> a 9� 1 �,' ° <br /> HOME ADDRESS �! Lo>'/ �� .�,� <br /> EMERGENCY/FIRE NUMBER A 9t)'d ROAD NAME C t fir„ E 1 <br /> ism l <br /> LEGAL DESCRIPTION(see tax receipt) ��jt� Q � �� 3 `a 9 � �-- <br /> i <br /> 0 <br /> Cl � <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE DDITION a <br /> S. <br /> M. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> y <br /> STRUCTURE/ADDITION USE: Gar <br /> a i rL�A <br /> (Home/Cabin;Com rcial Business; Bedroom; Deck;etc.) v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> O <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 " Q <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 <br /> 71 Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <br /> NORTH(N). fq c <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m v3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> STREAM OR RIVER. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS,ROADS,LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N S <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. G p <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE Cr <br /> ISSUED. = <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. t� <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 75 FEET OF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> z _ 3 � L <br /> .� a _ ; <br /> 6. v ! CH " o � T_. <br /> 7. <br /> ca! : i RI <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 o ' <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize o m E E m <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- y O <br /> sue a permit. I further accept all liability which mabe a u of the County of Burnett relying on this Information I am <br /> providing in this app Ice ' I agree t rrni un fficials charged with administering county ordinances or other m <br /> authorized person t ave cces o e a v sc d premises at any reasonable time for the purpose of in pection. -n : <br /> m : <br /> rP e . <br /> SIGN HERE �p �c Q <br /> ature of owner ctor) ( ate <br /> ZONING ADMINISTRATOR <br /> fA 40 40 h M <br /> ' N O O O <br /> TOWNSHIP PER TS MAY BE REQUIRED o 0 0 0 0 <br />