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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v ci Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r <br /> 1e ° <br /> y <br /> OWNErTo ki [`n r`��P + �[ TELEPHONE(2 tI'U' J g� <br /> HOME ADDRESS `IR\a G7���'JF f' �� `J4�� 1 <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER ROAD NAME .. <br /> `5C, 0 Lf`J(fl — SIS Ty �Rly w 0.cres <br /> LEGAL DESCRIPTION(see tax receipt) a_qP_ILI rI d 0qQ00 m <br /> DWELLING/BUILDINGGARA ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ y c <br /> TYPE OF PERMIT(S): Q <br /> FILLING/GRAD I CAMPI G UNIT ❑ S DIVISION ElM o; <br /> i V J 5. <br /> STRUCTURE/ADDITION USE: / / �J ��+ o Q <br /> (Home/Cabin;Commercial Busin ; Bedroom; Deck;etc.) y <br /> BUILDING CONTRACTOR: P <br /> v <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR m 3. <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O H <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T c C <br /> In Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. �A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m m O <br /> NORTH <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO IM ` 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. <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. 1 Q <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 PLANS2. <br /> �O <br /> MUST BE SIGNED AND DATED BY THE OWNER. ° <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN Cr <br /> NEEDED. - 1 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: 1 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT Q <br /> ISSUANCE. I <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. 1 <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 /> oma, d � 0 a m <br /> = rni [ m <br /> I declare that this application (including any accompanying schedule) has been,examined by me and to the best of my c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of m °�+ <br /> CL <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.09termining 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 a cess tS the ab described ppernises at an easonable time for the purpose of inspection. CD <br /> eo"-�V, <br /> m <br /> SIGN HERE <br /> (signature o erorb d ( ate) <br /> ZONING ADMINISTRATOR <br /> %J ki <br /> N N (l1NNtn (n <br /> °1 9n O°1 fT 00 <br /> O 0 0 0 0 0 0 <br /> T NSHIP PERMITS MAY BE REQUIRED 0000000 <br />