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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v 0 Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N <br /> R \, j/J� —7 t g { C <br /> OWNER r tib lM0n D �j 1/�It, 1 e7z cn / �6 Lt 6 6 Q Tq3 � <br /> �` (,)f/V'TELEPHONE <br /> m <br /> HOME ADDRESS <br /> EMERGENCY/FIRE NUMBER6vq 1 ROAD NAME G <br /> L co,,"r i S T*V1 c es <br /> LEGAL DESCRIPTION(see tax receipt) ` (9—/S—�� v 2. n /iEC/y f}�Id J'T/C .✓ y <br /> 1 (o <br /> DWELLING/BUILDING ® GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ to <br /> co <br /> TYPE OF PERMIT(S): o <br /> FILLING/GRADING ❑ CA (<J NG UNI ❑ SUBDIVISION ❑ �•a <br /> STRUCTURE/ADDITION USE: H0 <br /> /7I o <br /> Hom /Ca In; Commercial Bu ' ess; Bedroom; Deck;eta ro <br /> / � ee m <br /> BUILDING CONTRACTOR: A T ACJ 1` YG> E Ll o Q d, M e 1 <br /> 0 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 61/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 \\ <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 M _ vvv <br /> y c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T CL <br /> (D <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). W O t <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 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 1 <br /> BUILDINGS, ROADS,LAKE,LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 1 <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 /> ( O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN , q ° b <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z V <br /> 0 <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. • � <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY Dc <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> cSETBACK AREA.5. <br /> M 01 IT 8 <br /> 6. al `� 3 a in y qqQ,, M <br /> M C w <br /> 7. <br /> O <br /> 1yt m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m E <br /> that this information I am providing will be relied upon by the unty of Burnett Wisconsin in determining whether to is- v <br /> sue a permit. I further accept all liability which may t ares C my of Burnett relying on this information I am m <br /> providing in this application. 1 agree to permit county offi i ministering county ordinances or other m <br /> authorized person to have acce the a ove described p e s r t e for the purpose of inspection. T <br /> J m <br /> SIGN HERE <br /> (signature o o er building con*acto , (date) <br /> ZONING ADMINISTRATOR <br /> C ri En En <br /> N PNN(n <br /> O pt fn O <br /> TOW SHIP PERMITS MA' 0 0 0 0 0 <br />