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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator o 0 <br /> APPLICATION FOR LAND USE PERMIT�� <br /> 0 <br /> L ,4b� <br /> ` a <br /> OWNER G r F + /' TELEPHONE0 <br /> 3 <br /> a <br /> CD <br /> HOME ADDRESS 111 <br /> � T <br /> EMERGENCY/FIRE NUMBERa 3 72ROAD NAME �✓�� S t� <br /> LEGAL DESCRIPTION (see tax receipt) <br /> DWELLING/BUILDING I GARAGE/ACCESSORY STRU TURE 1:1ADDITION 1K PRIVY ❑ cn <br /> 0 <br /> TYPE OF PERMIT(S): it <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ g <br /> laX �a- ` <br /> STRUCTURE/ADO /D Y` <br /> STRUCTURE/ADDITION USE: � t` Sc..I -' ScZ �� 0 <br /> (Home/Cabin; Commercial Bu ' ss; Bedroom; Deck;etc.) 0 <br /> J m <br /> BUILDING CONTRACTOR: CD <br /> / <br /> C <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. <br /> �I N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <br /> "n <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. ;o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). y o <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO rn 3 <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. o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO Cj <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 <br /> 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a <br /> NEEDED. 2 <br /> Q-3 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> 0 <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 THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> CD M � MO CL m <br /> Oeov <br /> 6. COD <br /> mcy0 <br /> y9' 3 <br /> o : <br /> =W m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of aC <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- p <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. m <br /> CD : <br /> M : <br /> SIGN HERE <br /> (signature of owne or building contractor) (cfata) <br /> ZONING ADMINISTRATOR V/4, Cf)/Gfa1Yl <br /> cn cnwcn cn s»� <br /> N N<r NN<r rr <br /> Ut (1t O fT (n '0 O <br /> TOWNSHIP PERMITS MAY BE REQUIRED ° 0 0 0 0 0 0 <br /> 0000000 <br />