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0VI-) C-0-01A-le <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v o° o <br /> APPLICATION FOR LAND USE PERMITS . 4 <br /> r <br /> p }q w o <br /> / QQ -7IS- — 26 7570 � <br /> CL <br /> OWNER V 8 R V t4` S C i4 a G �� TELEPHONE IS _3 g'� 3 ll� m <br /> it <br /> HOME ADDRESS —f^�1 A O <br /> � 1(o LL)d (3iRCN ST. �MkRU � Luis. ' yea ! 'i <br /> r m <br /> 0 <br /> EMERGENCY/FIRE NUMBER �`7(o ROAD NAME C <br /> LEGAL DESCRIPTION(see tax receipt) PCA, /� T <br /> C� O V Y 4071 SFC,,Z7 1 �O �/ iR/6 <br /> e <br /> ca o <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE ADDITION cr <br /> C <br /> CL <br /> 5. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> co <br /> STRUCTURE/ADDITION USE: n77-/o &) L4c, fir <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. m <br /> 0 w <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T n <br /> In z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 0 ;b <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <br /> NORTH(N). to 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m v <br /> CENTERLINE OF ROAD, (C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> STREAM OR RIVER. <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS,ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N ry <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS ? 1� <br /> MUST BE SIGNED AND DATED BY THE OWNER. m o <br /> v � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE 0 <br /> ISSUED. 2 o Q) <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: ` <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT C) ) <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. XJ <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. <br /> a -0vr vvm <br /> 6. 30 1 <br /> v ! Cin o9' � <br /> lN : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my Cr C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- v <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 Coo i <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of Inspection. T <br /> M : <br /> m : <br /> SIGN HERE /e J O Al I <br /> -(Siignnaatuurre of ownerororr building contractor) (date) <br /> ZONING ADMINISTRATOR �10 H N 4S <br /> N N (TN0 <br /> N NO Vt VtOO <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0000000 <br />