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Mew <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -o0 Z <br /> APPLICATION FOR LAND USE PERMIT 3. <br /> `�') S r <br /> f/1 � <br /> 41 <br /> OWNER <br /> TELEPHONE <br /> m <br /> HOME ADDRESS <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt)Po M <br /> 0 <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION PRIVY ❑ a <br /> 0 <br /> TYPE OF PERMIT(S): Q <br /> FILLING/GRADING CAMPINGT El ON n <br /> �2 ry�Cc Ind a� <br /> STRUCTURE/ADDITION USE: C--e— o <br /> (Ho Commercial Busing s; Bedrooms eck�gtc.) <br /> BUILDING CONTRACTOR: (�—GZG( <br /> m <br /> v <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. T <br /> y <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p m <br /> n n <br /> -n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. <br /> n m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m T <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 <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 7 <br /> BUILDINGS, ROADS, LAKE, LOT LINES. M <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. 2 a <br /> o 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN 0 `F' <br /> NEEDED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: o <br /> 0 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT CN0 <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 THE REQUIRED WATER <br /> SETBACK AREA. (D M 0 M a :E kM <br /> 6. Volt m < 3 n m x a cD ."0 <br /> V -O C y N O 3_ <br /> 7. <br /> ♦/I — : <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ccnA <br /> C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of <br /> all information contained in this application(including any accompanying schedule)and I further declare that I m <br /> recognize 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 m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized pers o have access to the ab <br /> yescribed premises at any reasonable time for the purpose of inspection. m m <br /> m <br /> SIGN HERE <br /> signature o or wilding contractor // <br /> G (date) G <br /> ZONING ADMINISTRATOR V' <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> v <br />