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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872Hing Administrator a( T <br /> APPLICATION FOR LAND USE PERMITS C <br /> CD 0 <br /> 3 <br /> 0 <br /> H „� <br /> OWNER _ TELEPHONE 7(0 <br /> 00 f l <br /> HOME ADDRESS 7/ M <br /> EMERGENCY/FIRE NUMBER <br /> Ot ( ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) <br /> t 't I wP 03 <br /> CD <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ <br /> TYPE OF PERMIT(S): Q <br /> C <br /> FILLING/GRADING ❑ CAMPING UNIT [I SUBDIVISION E] � <br /> Q a <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin,Commercial Business, Bedroom;Deck;etc.) � <br /> BUILDING CONTRACTOR: ' 0)n /J r �J <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR � <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. m 3 (n <br /> DIRECTIONS FOR PLOT PLAN DRAWING, (AERIAL OR TOP VIEW) '� y <br /> O a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. - Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m 9 <br /> NORTH(N). C m <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO CO) <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF p <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. tn� Z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO W P <br /> BUILDINGS,ROADS,LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. O- <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. <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN a ) <br /> NEEDED. -� <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. n <br /> CONDITIONS OF PERMIT: Z <br /> 0 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT Q <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. � This structure to be used as private residential <br /> 6. garage/storage onl m = d; m <br /> habitation. y' Not to be used for human �. 0 o 3 <br /> 7. <br /> 0Z CD �'O 1 <br /> 1 declare that this application (including any accompanying schedule) has been examined by me and to the best of my Gm y <br /> M <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of i I, A <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize : CCD <br /> m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- L7 <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 <br /> m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other iu <br /> authorized person to have access to!,410o ve describe ises at <br /> nable time for the purpose of inspection. m <br /> m <br /> SIGN HERE <br /> (signature of n r or tiding contractor) ! (date) (Z <br /> ZONING ADMINISTRATOR <br /> ' stn fn cn vi w�' <br /> .INT .INT ITNINTOO <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 00 000 <br />