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*I <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 /> m O0 <br /> - m <br /> FL <br /> C <br /> OWNER <br /> recgr V t4S+ ekLe'c <br /> TELEPHONE ^p <br /> HOME ADDRESS `130' UC'(1 r I`0W �—-Gxle� r(�yeJ �1G ,M� <br /> EMERGENCY/FIRE NUMBER ROAD NAME Old <br /> LEGAL DESCRIPTION(see tax receipt) Govt Seea -1 yCA) P1 toW � y <br /> ur o <br /> TYPE OF PERMIT(S): DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE-ADDITION- <br /> 9: <br /> X S. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION ` <br /> w <br /> �5m q-/0 <br /> STRUCTURE/ADDITION USE: V. � <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR n <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 <br /> c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 CDin CL <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 0 � <br /> 2 .SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE M on <br /> NORTH(N). U) <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 LAKE, Z <br /> STREAM OR RIVER. 0 <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILDSb <br /> - <br /> INGS, ROADS, LAKE, LOT LINES. O <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. t <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. coo UJ <br /> o � � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE _r <br /> ISSUED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c J <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. CJ <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. 3-00r' a am <br /> m �v= ."0 <br /> 6. mm3 <br /> Z : m c <br /> 7. _ <br /> o : ur i 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 <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m rn <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- O <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this information 1 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. n <br /> CD : <br /> SIGN HERE <br /> (sig-nature off owner or building contractor) (date) ' . <br /> ZONING ADMINISTRATOR tl l 1�/aSl <br /> • wwu�www`(A <br /> ,tr NONN0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED O0 0 000 0 <br />