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Ow <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 C) Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r <br /> UT O <br /> ) <br /> 1 S5- o �1- RAS G:O(Q 3o <br /> OWNER l:C7[.A �L TELEPHONE <br /> HOME ADDRESS L_D Rn ! O <br /> r � <br /> ^�7 / ` o <br /> EMERGENCY/FIRE NUMBER dJ lrtb ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) Cn <br /> CD <br /> Cl <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ 0' <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ ((�I a <br /> 11 V y' <br /> STRUCTURE/ADDITION USE: f%?A- SISAe vr 0 ` <br /> (Home/Cabs; Commercial Business; B room; Deck;etc.) Cf) <br /> BUILDING CONTRACTOR: �r�ny�ea.��2 4�Linc�Sdn Grt�n�5�tnt4 �' <br /> v <br /> m <br /> CD <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 /> ZI N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O m <br /> n a. <br /> -n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. <br /> n m A <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 m 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. o <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. C>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 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o l <br /> f <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN o 0 <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. z <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. ( C( <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> ;o -00 > 0 > 0 -0 <br /> C . d 0 M a m <br /> 6. (D 3 n m �c = .� <br /> (D C <br /> 7. z y 0 0 ' <br /> O T G <br /> Q <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 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 EL <br /> m <br /> CD <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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to 4ave access to the above described premises at any reasonable time for the purpose of inspection. fD <br /> m <br /> ID <br /> SIGN HERE <br /> (signature of owner or bui ng a (date) ~Q'' <br /> ZONING ADMINISTRATOR Z �J <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />