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v/ I ev" / / <br /> BurnethCounty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator o 0 <br /> -0 <br /> APPLICATION FOR LAND USE PERMITS 3. 4 <br /> �t � * r <br /> OWNER GQ�� C1 I 1 j - `'l �i j � <br /> l.( {'1.So1 TELEPHONE a <br /> � — / <br /> � m <br /> HOME ADDRESS6' <br /> g)3 t ( UJ0 ���n� lis, Sia <br /> 0 <br /> p r1 0 <br /> EMERGENCY/FIRE NUMBER �g 3 1 ROAD NAME �o rl h p✓ ICRP ~ <br /> i <br /> LEGAL DESCRIPTION(see tax receipt)L3 C 5,vn ca {� <br /> � o <br /> �]7 N <br /> TYPE OF PERMIT(S): DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE /6DDITION 07 Q <br /> a <br /> S <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0ca () , <br /> L�`v;n� Prez (J r <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 O C <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -� <br /> x � <br /> DIRECTIONS FOR PLOT PLAN DRAWING• (AERIAL OR TOP VIEW) � ig. <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m ° <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m Q 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. (V <br /> 1 <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS C <br /> MUST BE SIGNED AND DATED BY THE OWNER. m c N <br /> o 9 �j <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> Cr CO. <br /> ISSUED. 6C <br /> C, <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: 0 <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 /> v 9Cwwo33 <br /> 7. Z �' CDQ 7� ;ao : <br /> .N: <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c E 10 <br /> knowledge and belief it is true,correct and complete. 1 acknowledge that I am responsible for the detail and accuracy of m E '• S <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize i io m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- i E p <br /> sue a permit. 1 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. 1 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. -, <br /> m <br /> SIGN HERE p.hinnp <br /> (signature of dwner or building contractor) (date) i <br /> ZONING ADMINISTRATOR l I.mIdnl,t�n I h <br /> N N H 4440 <br /> N N OM N N(T N <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />