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01) c.(A7_AP1' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator c _0 -- 0 <br /> APPLICATION FOR LAND USE PERMITSTO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for th work <br /> m <br /> described and located as shown herein. The undersigned agrees that all work shall be done in actor- 3 � <br /> dance with the requirements of the Burnett County Land Use Ordinance,Sanitation Code,and with a I other <br /> applicable County Ordinances and the laws and regulations of the State of Wisconsin. y m 1 <br /> OWNER TELEPHONE 7 - v <br /> �AJ It Ep6r (pI - 93 -3 o <br /> I <br /> HOME ADDRESS 31 ASS'J ooi) c ail— r �A M t-4S5"5,;.-I f't n) � 3 -7rr,,• S <br /> EMERGENCY/FIRE NUMBER / ROAD NAME �ra %5 ® ) I L <br /> LEGAL DESCRIPTION (see tax receipt) � e, ooq <br /> / <br /> Ir <br /> CONTRACTORrmlr <br /> l� 6 <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION 0 <br /> CTN <br /> O <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION <br /> / QZ 'o <br /> STRUCTURE/ADDI ION\\USE: h � ' l/ De o 3 <br /> �aJ (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE Co <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) O 3 <br /> T v rn <br /> 1. All required dimensions or distances to be shown or drawn to scale. o a <br /> 2. Show the location and size of all existing buildings(EB) and all new buildings (NB)and indicate m y: <br /> North (N). y 3 <br /> 3. Show dimensions in feet of the following: (a) building(s) to all lot lines, (b) building(s)to centerline of m I <br /> road, (c) building(s) measurement to the ordinary high water mark(OHWM)of lake, stream or river. <br /> 4. Show the location of the well (W), septic tank (ST) and drainfield (DF), and all distances to buildings, <br /> roads, lake, lot lines. I <br /> 5. 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, contractor, etc., the plans mus be <br /> signed and dated by the owner. UI <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION E- ° <br /> FORE A PERMIT CAN BE ISSUED. <br /> o <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. e <br /> CONDITIONS OF PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMI <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 I F <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC., ALLOWED WITHIN 75 FEET OF HE <br /> 5. <br /> OHWM OF LAKES, PONDS, IVER UNLESS SPECIFICALLY PERMITTED. <br /> �ht -r- m S� -t-6 <br /> f <br /> 6. <br /> 7. <br /> L < m `� NOOO <br /> 6. , i»n <br /> O ' M <br /> i i 62 i i m <br /> of 'mom : D <br /> nn� i i m ip C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my m <br /> knowledge and belief it is true,correct and complete. I acknowled a that 1 am responsible for the detail and accuracy of m <br /> 9 P 9 P Y and m ; O <br /> all information contained in this application(Including any accompanying schedule)and I further declare that I recognize o o <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining wheth r to is- <br /> 6f <br /> b <br /> o : o : <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 O p <br /> providing int ' a plication. I agree to permit county officials charged with administering county ordinances other 3 ? 9 <br /> authorized peHion ttpma accessef+Qilrla�tiga described premises at any reasonable time for the purpose of insp ction. m m <br /> SIGN HERE <br /> ( gnat of ow or r b dl g contractor) ( ata) <br /> {. o <br /> ZONING ADMINISTRATOR <br /> v+fA� T <br /> TOWNSHIP PERMITS MAY BE REQUIRED o . . o v, u, v o m <br /> '� o0000000r/1 <br /> SrtT -aX, <br />