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C�'GCS"kZ� <br /> BurnettCounty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v G) Z <br /> APPLICATION FOR LAND USE PERMITS 3 ° <br /> — r <br /> M O <br /> HM 6:5-1 ---2'zS- 7-lcll CDC <br /> OWNER TELEPHON o <br /> 7d3 3� eSn o \ <br /> HOME ADDRESS J3 �� _`� 79�4 �>� �Q�iRc�M AA hly 0 /�ti g <br /> 0 � p� <br /> EMERGENCY/FIRE NUMBER ROAD NAME ff;rC! PA -ry <br /> / <br /> LEGAL DESCRIPTION (see tax receipt)N f.rA �� Zia / A J0 p 1`p�J.AE k <br /> DWELLING/BUILDING W GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY 0 <br /> TYPE OF PERMIT(S): c� <br /> FILLING/GRADING ❑ MPING UNIT ❑ SUBDIVISION ❑ c°V� <br /> STRUCTURE/ADDITION USE: �✓t/ O <br /> oma/Cabin; Commercial Business; Bedroom; Deck;etc.) rn <br /> BUILDING CONTRACTOR: <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. -n — <br /> O <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O <br /> -n a <br /> TI Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO lytt ^� <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF <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. <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N _ <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS <br /> Ct S o0 <br /> O 9 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN o <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z r <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. r <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY (A <br /> PERMITTED. '3 ti -Ij <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER q <br /> SETBACK AREA5. <br /> . pay l <br /> m <br /> a rncv `" o � 3 <br /> 7. Z y m <br /> o � <br /> .'G <br /> � : I m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my p <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of Q im C <br /> all information contained in this application(including any accompanying schedule)and I further declare that 1 recognize D 'm : : . <br /> that this information I am providing will be relied upon by the County of BurngttlN�gpsin in determining whether to is- ? m <br /> sue a permit. I further accept all liability which may be a result of the County$p r grrelying on <br /> this information I am <br /> providing �: <br /> p gin this applic 1 agree to permit county officials charged with admlr5temg county rdinances or other m <br /> authorized perso av c es o the above cjqscrIbed premises at any;reasonable time for-th ,�pryos�ejof irillspection. m <br /> CD <br /> SIGN HERE ` e P� v�Ot 0U <br /> (signature of r or uilding contrac or (date) <br /> ZONING ADMINISTRATOR <br /> fn to to to fo to <br /> .. � N NOiNN(r Vt <br /> Vt V7 O N Ul O O <br /> TOWNS P PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />