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&40)9-W <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator 'a o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> c V - <br /> m <br /> OWNER TK TEL EPHONE/�57, <br /> HOME ADDRESS y;�7y (,yc--7S7-(a1) 6j6y SiqQR6711I 10K) �C_ /� O <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER 6q--7 <br /> ( 7 ROAD NAME v�lT <br /> o � <br /> LEGAL DESCRIPTION (see tax receipt) ea T cn <br /> m <br /> �,r�� <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION PRIVY F-1J� cn 0 <br /> TYPE OF PERMIT(S): ' <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ Q' <br /> n <br /> STRUCTURE/ADDITION USE: A71c ° <br /> Home/Cabin; Commercial Business; Bedroom; Deck; etc.) cn <br /> SE?—Pk m <br /> BUILDING CONTRACTOR: cSEZ.T <br /> iu <br /> m <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. T <br /> � G <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <br /> In <br /> T �Q Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 0 m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m m <br /> NORTH(N). N <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 o <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. <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. --z C> <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. i 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. O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN <br /> NEEDED. �i UJ <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: 1 <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 AL HORELINE. 1 <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLES!ip \1 a <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED IN� � Q rlyJ <br /> SETBACK AREA. <br /> 5. <br /> D D 'G <br /> � � 0ci 00 R M <br /> 6. Q �� ma. m xc <br /> / f1 am! � Z : N <br /> jo j 3 <br /> on <br /> _ Cnm <br /> I declare that this application (including any accompanying schedule) has been emm me- firld to the best of my 0 A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of a <br /> M <br /> all information contained-in this application(including any accompanying schedule)and I further declare that I recognize Cxy ` <br /> 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 <br /> authorized person to have access to the above described premises at any reasonable time for the p rpose I inspection. m <br /> M <br /> M : <br /> SIGN HERE XI <br /> (sig ure of owner or buildi c ractor) date) <br /> ZONING ADMINISTRATOR <br /> -5Y6 V-&u pct Ifouuc-e - be �J 11 <br /> TOWNSHIP PERMITS MAY BE REQUIRED///39, 6-0—t-QyJ.v <br /> Sh p 1-a•1-v I 15g,�Y7 -POVy <br />