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cvxr(p <br /> Burnett County 7410 Co. Rd.K, No.'102, Siren,WI 54872 Office of Zoning Administrator 07-) <br /> APPLICATION FOR LAND USE PERMITS <br /> 0. <br /> ^• r <br /> OWNER G <br /> ✓)1 r,(- S S !� TELEPHONE O �a� _ e3 7 F o <br /> d <br /> n �— lir <br /> HOME ADDRESS� & 7 �� 0/4 P Z" �J I�/,� � L^� � w � 0 <br /> ►V <br /> EMERGENCY/FIRE NUMBER G 9 T ROAD NAME n t <br /> LEGAL DESCRIPTION(see tax receipt) s c <br /> e <br /> w <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE�_ADDITION c <br /> a <br /> S. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION <br /> y <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. m <br /> DIRECTIONS FOR PLOT PLAN DRAWING• (AERIAL OR TOP VIEW) O <br /> M Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m jp <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <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 LAKE, Z <br /> STREAM OR RIVER. o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS, ROADS, LAKE, LOT LINES. <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 PLANS 0 W <br /> MUST BE SIGNED AND DATED BY THE OWNER. m so <br /> O 9 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE q <br /> ISSUED. e <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <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 <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 /> ggX U0rg0gO -0 <br /> 6. 7d 3 n 3F R.N o : =m 3 <br /> 7. Z : !^ (D,2 <br /> o <br /> =N: <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 res ' " c <br /> g p g responsible for the detail and accuracy of ' <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize eo i <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 to the above described premises at any reasonable time for the purpose of inspection. r <br /> CD : <br /> SIGN HERE <br /> (signature o�or bul ng contractor) <br /> (date) <br /> ZONING ADMINISTRATOR e�1!Yl )VIG�i 1 '• `• '• `• `• <br /> N N UI N N UI <br /> UI VI O UI VI O P O <br /> TOWNSHIP PERMITS MAY BE REQUIRED '30000000 <br />