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N( <br /> Office of Zoning Administrator -CD 0"/ o 0 <br /> BurrVitt County 7410 Co. Rd.K, No. 102, Siren,WI 54872 3 0_ <br /> APPLICATION FOR LAND USE PEWITS �7yg N <br /> 2OS— 6-737 <br /> CE CC < 5 ) -7 s— -75 <br /> --� L TELEPHONE ,* 2B o <br /> OWNER <br /> Q , wT � Q <br /> HOME ADDRESS G S� 94I/6F� Cl r'"-' ^�i`f' W m r' <br /> i <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> CD <br /> LEGAL DESCRIPTION (see tax receipt) O -1/6 <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ c <br /> c <br /> 4 <br /> TYPE OF PERMIT(S): `F <br /> FILLING/GRADING 11CAMPING UNIT ❑ SUBDIVISION ❑ LA. n + <br /> STRUCTURE/ADDITION USE: M �� Cn <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) <br /> BUILDING CONTRACTOR: M �'IL C..NS �~ I!1 oz Sy // per 49L <br /> v <br /> N <br /> 3 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'/]X 11 SHEET OF PAPER. ANY INCOMPLETE OR A m <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O G <br /> n,o�rrinNS FOR PLOT PLAN DRCL <br /> AWING: (AERIAL OR TOP VIEW) -n (�t <br /> n m ) <br /> m <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. C o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). 5)TO ALL LOT LINES, BUILDING(S)TO <br /> 3 SHOW CENTERLINE OFF ROAD,(C)BUILD NG(S)MEASUREMENT TO THE(ORDINARY HIGH WATERMARK(OHWM)OF m c <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. o <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. O c a <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLAN 1 . <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN �q o <br /> NEEDED. Z (� <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. P �, <br /> CONDITIQNa OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT I< <br /> I <br /> ISSUANCE. W <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. A -0 n r- m F1W 0 CL m <br /> 5. yreo� 3_ <br /> mCm =U3N N O � <br /> 6. o : CO <br /> m <br /> 7. 0 <br /> I declare that this application (including any accompanying schedule) has been examined by me and it and the best ac o c e <br /> knowledge and belief it is true,correct and complete. I acknowledge that Isacm rese) d I further declare that Icrecognize fD G <br /> all information contained in this application(including any accompanying_ 0 � .h i I determining whether to is- <br /> that this information I am providing will be relied upon by the Count r I on this information 1 am <br /> Y ��� <br /> ° J ordinances or other �^ <br /> sue a permit. I further accept all liability which may be a result of the Coun ��.... �`��'� <br /> application. I agree to permit county officials charged wit a mile i e f he pose of inspection. -n <br /> providing in this app m <br /> authorized person to have acc ss to the above described premises a!any r ble aim P <br /> SIGN HERE C�V (date) <br /> nature of owner or it ' g a <br /> L9 40 46S 49 4A 40 <br /> ZONING ADMINISTRATOR �ZONIN <br /> ^„ N o rNi 0 0 <br /> L1 �� `� ?/ �7 0000000 <br /> TOWNSHI PERMITS MAY BE REQUIRED P 5 'a <br />