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on(6q� <br /> Burnett County 7410 Co. Rd. K, No. 102,Siren,WI 54872 Office of Zoning Administrator W o 0 <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N 0 <br /> r C <br /> OWNER _. f TELEPHONE yid a sis�s� <br /> ^p <br /> HOME ADDRESS 7 <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) 02r <br /> a <br /> TYPE OF PERMIT(S): DWELLING/BUILDING STRUCTURE ADDITION a <br /> Na <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 50 <br /> w <br /> m <br /> STRUCTURE/ADDITION USE: N\bU(Z- E-)(I TIAJ O 1�4 J� 6A4t4-.fj20K 1 L-A1CC fi+ <br /> (Home/Cabin;Commercial Business; Bedroom;Deck;etc.) CL a & <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR .n 3 `e <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 <br /> H <br /> c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) <br /> �t ii <br /> ?r O 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 C c <br /> NORTH(N). rn 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m KJ v <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, ( c <br /> STREAM OR RIVER. <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- (y <br /> INGS,ROADS, LAKE, LOT LINES. ,I�JVC1 <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. o . <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> ISSUED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONDITIONS OF PERMIT: r7m r <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. c r <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. m m m RppRO L 0 <br /> IPS Q tam A <br /> 6. S �er� )/-3- 1'7 am <br /> Io <br /> 7. J i x <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a E <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m <br /> that this information I a v(ding will be relied upon by the County of Burnett Wisconsin In determining whether to is- m <br /> sue a permit. I furt accept I liability which may be a result of the County of Burnett relying on this information I am m <br /> providing in this plication. I gree to per it c my officials charged with administering county ordinances or other E i <br /> authorized pare n to have ac stq4he a ve scribed premises at any reasonable time for the purpose of Inspection. <br /> m : <br /> 1,36 <br /> SIGN HERE <br /> .( <br /> (a gna*oneurslding contra r) (dateZONING ADMINISTRATOR w f^f^H <br /> Poc� PPP <br /> 000000 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />