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? C- <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 w <br /> 1 TELEPHONE <br /> OWNER <br /> O <br /> HOME ADDRESS G/�� �� j� S� /(,! 461 L/. 5 Ad• �" ��f <br /> r <br /> // o_ <br /> EMERGENCY/FIRE NUMBER ROAD NAME fQr �l k a ke Dr. <br /> Loi v/ 1'R. SF%f & P 444, S1014/ 6rvero,ext \ <br /> LEGAL DESCRIPTION(see tax receipt) Ln d see, /7 rVI AI R /SQL/ 3W;:-S &V <br /> y 0 <br /> TYPE OF PERMIT(S): DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTUREADDITION a <br /> S <br /> w. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION rn <br /> STRUCTURE/ADDITION USE: c <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR In 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. X H <br /> DIRECTIS FOR PLOT PIAN DRAWING: (AERIAL OR TOP VIEW) A <br /> ONz <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 c <br /> NORTH(N). M <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO rn v <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, 1 oz <br /> STREAM OR RIVER. f ,r <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- D `N <br /> INGS,ROADS,LAKE,LOT LINES. <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 S o <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE g S <br /> ISSUED. <br /> z <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. <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. ;a -0 m m m <br /> do <br /> 6. i It w <br /> o f CA i i A <br /> 7. =er : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my i G~3 i c <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of CA ' ; <br /> all Information contained In this application(including any accompanying schedule)and I further declare that I recognize G <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- m <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 m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> / H : <br /> SIGN HERE '' ''z ! >bY <br /> (signature <br /> eoor owner orr.building <br /> g"cconnttractor) (date) <br /> ZONING ADMINISTRATOR u �m ^' 'I(^�+ , N M ri N 4901 <br /> N fn O PfJ�00 <br /> O 0 0 0 6 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />