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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872Office of ��� <br /> APPLICATION FOR LAND USE PERMITS Hing Admin4trator o 0 <br /> 0 z <br /> 3 <br /> r <br /> OWNERTELEPHONEo <br /> HOME ADDRESS <br /> U <br /> EMERGENCY/FIRE NUMBER � ,°r. <br /> ROAD NAME <br /> /)n t <br /> LEGAL DESCRIPTION(see tax receipt) CD <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE El ADDITION ❑ PRIVY ❑ ) <br /> TYPE OF PERMIT(S): o <br /> FILLING/GRADING ❑ CA ING UNIT ❑ <br /> SUBDIVISION <br /> STRUCTURE/ADDITION USE <br /> N <br /> (Home/Cabin, Commercial Business, Bedroom; Deck;etc.) o <br /> BUILDING CONTRACTOR: C/) <br /> m <br /> d <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR v <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 3 <br /> T - IWD4�3 DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) <br /> CL <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. O p <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE Im c <br /> NORTH(N). m <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m3 <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. <br /> 4. SHOW THE LOCATION OF THE WELL Z <br /> BUILDINGS, ROADS,LAKE, LOT LINES SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO a <br /> CONTRACTOR, <br /> INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER, TOR, ETC.,THE PLANS N <br /> MUST BE SIGNED AND DATED BY THE OWNER. 0 <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN o <br /> NEEDED. +, <br /> T <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. 1 <br /> CONDITIONS OF PERMIT: Z <br /> 0 <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. '1v <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY \ Q^ <br /> PERMITTED. r ' ) <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> 6. <br /> -0 C) rDp > <br /> LD3 a m x a cD � <br /> Z : N 7. <br /> m o : 1 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the bestof my <br /> o T A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m' �_ C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m o : 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 CD <br /> m i7 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m : <br /> m : <br /> SIGN HERE m <br /> (signature of Her r b"ng contractor) <br /> (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />