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& ( J' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v o <br /> APPLICATION FOR LAND USE PERMITS , �Q <br /> OWNERL �y TELEPHONE G�� /�6 ���� m <br /> Al � <br /> L1. .HOME ADDRESS / Oq 6• // v � e/2C lG 47AI <br /> 1 = o <br /> EMERGENCY/FIRE NUMBER ROAD NAME bA K6 Rd <br /> qO <br /> LEGAL DESCRIPTION(see tax re ce p�, A j3 =g7! D ao d QRCS <br /> 0 <br /> / Vl � <br /> TYPE OF PERMIT(S): DWELLING/BUILDING V GARAGE/ACCESSORY STRUCTURE ADDITION n <br /> 5. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION � Jv <br /> m <br /> or <br /> STRUCTURE/ADDITION USE:_ C4 13 <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) T <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR In 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. a <br /> kc�' <br /> DIRECTIONS FOR PLOT PLAN DR WA ING_ (AERIAL OR TOP VIEW) n o. <br /> n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE N c <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m M <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, ( o <br /> STREAM OR RIVER. <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- 1 <br /> INGS, ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. c C\ <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS <br /> 0 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE n _ <br /> ISSUED. Q <br /> Z <br /> I r <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. P <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 75 FEET OF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. � � mr g� � m <br /> 6. » i g! No !" �m3 <br /> 0 : gIQ <br /> 7. o <br /> co i . m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my L'�f • • i C <br /> knowledge and belief it Is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of <br /> all information contained in this application(including any accompanying schedule)and 1 further declare that 1 recognize M <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- m <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 tigurPose of Inspection. <br /> SIGN HERE �' f ate <br /> (signatu f or ull { <br /> ZONING ADMINISTRATOR 44 40(dam'w 40 N <br /> 0 <br /> 0 <br /> 0 <br /> 0 , O <br /> 0000 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 <br />