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�C <br /> Burnett County 7410 Co. Rd.K, No. 102,Siren,WI 54872 Office of Zoning Administrator -0 0 Z <br /> APPLICATION FOR LAND USE PERMITS _ <br /> d w o <br /> OWNER 7V /N 6 1CQtl rL—Sd-vt, TELEPHONE <br /> Q7�5,}o�S/_. �9',�•'� <br /> •W F� Ay <br /> HOME ADDRESS (io2S—� LO w4 AD CA�tt J3 (� 4*4? LA.,10 <br /> EMERGENCY/FIRE NUMBER ROAD NAME 1.0 �(f �4 O. <br /> LEGAL DESCRIPTION(see tax receipt) 1 b 'p l C <br /> C4 <br /> �. <br /> N <br /> TYPE OF PERMIT(S):DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION C <br /> w' <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> STRUCTURE/ADDITION USE: 4W 6LVAA, 160 1 8 V ,I✓ftp ►a i X/G ber c <br /> usiness;Bedroom;Deck;etc.) 'a <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE O <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) `r �}ti►7►r�ct Yltt O CL Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m a <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE rnfir <br /> n <br /> NORTH(N). y C <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 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- U <br /> INGS,ROADS,LAKE,LOT LINES. 0Q <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> ISSUED. <br /> I <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. G <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. Ag <br /> � 3 n 3 of M <br /> n _ <br /> 6. � 9 m '" o= m <br /> Z <br /> 7. o CAI fi m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ZS g E E ? 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 al a, : m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m 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 m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other m <br /> authorized person to have access a above described premises at any reasonable <br /> tz <br /> SIGN HERE 7 <br /> Ig ature nor or building contractor) <br /> ZONING ADMINISTRATOR w 40 W d, h <br /> NNNN c" <br /> u7 O!M P. O <br /> O <br /> 0000 <br /> TOWNSHIP PERMITS MAY BE REQUIRE 0 0 0 0 0 <br />