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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o° �o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> N <br /> OWNER a TELEPHONE <br /> F, lPu� a i � h m�l �r, 71J- 10 <br /> HOME ADDRESS �/ R1 1 .SQ � t �� <br /> m <br /> qo <br /> / � o <br /> EMERGENCY/FIRE NUMBER �O JC D ROAD NAME Q R POI n7 R� <br /> �a /1 ACRes <br /> LEGAL DESCRIPTION(see tax receipt) S 3 al T3 7� /d'Co Op y 70 <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ c <br /> TYPE OF PERMIT(S): or <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ Q �f n <br /> STRUCTURE/ADDITION USE: 14Ol'n � �X 5c;? l� 1 / IT GI • &M tp � 0 <br /> (Home/Cabin;Commercial Business; Bedroom; Deck; ) i y) <br /> BUILDING CONTRACTOR: <br /> CD <br /> p ce <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'/1 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O IV/ <br /> z N J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 I_ <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> �l � <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C 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 Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. , P <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. pC <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <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 /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN a ° 1 <br /> NEEDED. 1 <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 1 R Cj <br /> ISSUANCE. X/ <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 r r, <br /> SETBACK AREA. " <br /> 6. fl ^ _c�C' A�Q a ppe-a���r h/ e ^b ee� n�e t C a �_ <br /> 7. l� —_ V• /� `-J(+`.-'� " W[ / Kms.. <br /> z :: y O O <br /> O <br /> �"• m <br /> 1 declare that this application (including any accompanying schedule) has been examined by me and to the best of my Zi c p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a C <br /> all information contained in this application(including any accompanying schedule)and I further declare that 1 recognize N mm <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- �: m 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 described premises at any reasonable time for the purpose of inspection. <br /> m : <br /> m <br /> SIGN HERE ILO <br /> (sign a of owner or build contractor) (date) <br /> ZONING ADMINISTRATOR y,w'A d,d,w <br /> N NN(nONV• NfnO (rO Vt <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0000000 <br />