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071 conv, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o <br /> APPLICATION FOR LAND USE PERMITS <br /> pN 0 <br /> / <br /> 1I �P�'L�JSI-7ZSJ C <br /> OWNER �r e i J Q.Qt'l hL �C.l hrlr�F"i TELEPHONE 8"^ 8 y i$- t7 <br /> m <br /> HOME ADDRESS y�3� 17o��[°tihe� LrciL ��4�� IL Vn� SS qV1 9 <br /> w <br /> EMERGENCY/FIRE NUMBER 8 02(P ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) LV'r dl Csm UO <br /> Q <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE ADDITION a <br /> 5. <br /> N _ <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 s <br /> STRUCTURE/ADDITION USE:'do Vie 1.414 'IX�ON 'k- (l W.L IT <br /> (Home/Cabin; Commercial Business; Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> m <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. C <br /> � O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 B <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 'ro <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TOrn f �C 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, �/\ ] Z <br /> STREAM OR RIVER. <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS, ROADS, LAKE,LOT LINES. CP <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 1 <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS L <br /> MUST BE SIGNED AND DATED BY THE OWNER. o S <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE a <br /> ISSUED. 0' <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: t _ <br /> Aj Q <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. I <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. S'etg*C k. Avemy I s o ver 6(r - Qae.S rf d-Ar'hu, TRK 6*W,4444f <br /> zM vL <br /> ca 00 UO2 <br /> 7. <br /> O �U <br /> m <br /> 1 declare that this application (including any accompanying schedule) has been examined by me and to the best of my G�1S C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of i ; ii <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognizeN 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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other '• W E E <br /> authorized person t ave access tqAttp above described premises at any reasonable time for the purpose of Inspection. -n <br /> m : <br /> m ; <br /> SIGN HERE <br /> L `2 - rss7 <br /> signs re of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR v'm i /�'► u�dn N 44 440 N N fT <br /> vi "Mr) roo <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0000000 <br />