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"V ` ly <br /> 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 /> N O \ <br /> � N <br /> C <br /> a <br /> OWNER TELEPHONE o <br /> O <br /> HOME ADDRESS <br /> CD <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) 1 �� Sln / CD <br /> fff 111dddCD <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCT RE ❑ ADDITION 11 PRIVY ❑ N <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑_ CAMPING UNIT ❑ SUBDIVI 10 <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; Commerci I Business; Bedroom; De tc.) U <br /> BUILDING CONTRACTOR: <br /> 1'7 <br /> m <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/3 X 11 SHEET OF PAPER. ANY INCOMPLETE OR3. <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T — f„ <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 o <br /> -n <br /> T 0 Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> C C) <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. ° <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 0, <br /> MUST BE SIGNED AND DATED BY THE OWNER. O I , <br /> v � tJU <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN ° <br /> NEEDED. <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. I <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 /> 5. <br /> CD 'Uw r 0 CD O a 0 M <br /> v <br /> LD. 3 nm x �' � <br /> 6. Cy ^ o 3 <br /> o <br /> 7. on'� <br /> = rn : m <br /> 1 declare that this application (including any accompanying schedule) has been examined by me and to the best of my rG1 c C_ <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 I recognize fDCD 0 <br /> M <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- <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 1n this application. I agree to permit county officials charged with administering count ordinances or other o <br /> P 9 PP 9 P tY 9 9 Y C <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. T <br /> m <br /> m <br /> SIGN HERE { t <br /> (signature of o er o building contractor) (date) "_ '� . <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED " <br />