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cyt/ Cerny <br /> Burnett County 70410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> ai O <br /> OWNER /?D 06ef /T P e5 „ TELEPHONE 7 <br /> m <br /> HOME ADDRESS <br /> `1 (1 111 <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> r— <br /> LEGAL DESCRIPTION (see tax receipt)5E ql— // pC c <br /> a <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION PRIVY ❑ <br /> TYPE OF PERMIT(S): rn <br /> FILLING/GRADING ❑ CAMPy4G UNIT ❑ SUBDIVISION ❑ <br /> STRUCTURE/ADDITION USE: �� l� �j <br /> (H a/Cabin' ommercial B ness; Bedroom; Deck;etc.) y 4z <br /> m <br /> BUILDING CONTRACTOR: At, /V>• P � G(l it/ e r 6--f �� -�-,• <br /> v <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 /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <br /> Z! z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 0 d <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m ;? <br /> NORTH(N). o <br /> C7 <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 Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. P <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 /> S. 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. ' c <br /> O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN C o <br /> NEEDED. <br /> to <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: P <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. _n <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. v <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. 67 <br /> 5. <br /> 6. ' � 3 a A <br /> 0 a <br /> f�D C N M G 3 <br /> 7. o f i i i <br /> O . <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 ofm 0 ( '• C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- <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 emiae t any reasonable time for the purpose of Inspection. m <br /> m : <br /> a m : <br /> SIGN HERE e <br /> (sign u e of owner or build contractor) (date) <br /> ZONING ADMINISTRATOR d '• '• d, <br /> 40' <br /> NOU�TOWNSHIP PERMITS MAY BE REQUIRED 0 c 0 0 0 0 0 <br /> 000000 <br />