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amo <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator Z" G)G " Z <br /> APPLICATION FOR LAND USE PERMITS <br /> r <br /> OWNER �JLjF� )STELEPHONE <br /> oZ`� 'a <br /> o �+ O <br /> HOME ADDRESS t 0 <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> I <br /> ()IV <br /> DESCRIPTION(see tax receipt) e)OU � tc /k SeC l � co <br /> co <br /> o <br /> TYPE OF PERMIT(S):DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE ADDITION Cr <br /> C <br /> Cr <br /> a \ <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION c' 3( <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. n 3. <br /> a <br /> DIRECTIONS FOR PLOT PLAN DRAWING- (AERIAL OR TOP VIEW) G I' <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). a �- <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m I <br /> CENTERLINE OF ROAD, (C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, <br /> STREAM OR RIVER. Z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- c <br /> INGS, ROADS, LAKE, LOT LINES. <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. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFOREA PERMIT CAN BE <br /> ISSUED. ° <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONDITIONS OF PERMIT: o <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. <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 /> 6. = <br /> 3 c '�E L m <br /> g_ <br /> 7. 9 : low <br /> > > <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my Zg� i A <br /> knowledge and belief It is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of 2 <br /> all information contained in this application(including any accompanying schedule)and I further declare that 1 recognize i m o <br /> that this Information 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Is G)i m <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 ` CPE <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> M NN H N(A� <br /> N N)01 NN(TN <br /> ut N ON f7i00 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 40 0 0 0 0 0 0 <br />