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Q-4 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - i; o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> y O <br /> N <br /> G <br /> (D <br /> OWNER TELEPHONE (\ <br /> c? n <br /> HOME ADDRESS.,) IIa IIS + ) o TW <br /> EMERGENCY/FIRE NUMBER � ROAD ':13bic 1 m 1 <br /> oaoa 5G SLJ <br /> LEGAL D IPTION(see tax receipt)5 �(p� 10 a _( 0_ I(p-3� _b da 0 <br /> �A <br /> DWELLING/BUILDING 1:1GARAGE/ACCESSORY STRUCTURE 1.2 ADDITION ❑ PRIVY (n 0 <br /> TYPE OF PERMIT(S): CL <br /> Q <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ �?,�} £.� <br /> STRUCTURE/ADDITION USE: �. � � I % I�0 h S t i 7 Y'C , <br /> (H5 <br /> 'm1e//CCabin; Coo/m�mAerciaf B� usl ei�edroom; beck;etc.) U <br /> BUILDING CONTRACTOR: CD <br /> ICI 1l li L�JT1L 1 L! IV C_1 Si <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR � 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> c d <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) CL <br /> -no Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. fD <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m m <br /> NORTH <br /> 3. SHOW D M)ENSIONS IN FEET OF THE FOLLOWING: (A)BUILDINGS)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 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. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N o <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 0 t � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q V <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: p <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. t <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 THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> ;0 v W CD rn <br /> 6. CD 3MQNc ' 3 <br /> v C w o 0 <br /> N <br /> 7. o ^ h <br /> _U) <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my G) � IS <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of n <br /> all information contained in this application(including an accompanyingschedule and I further declare that I recognize PP f 9 Y ) 9 m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other : (D <br /> authorized person to have acce9q to the above described premises at any reasonable time for the purpose of inspection. ,� <br /> - <br /> SIGN HERE 31 — P®� <br /> sig afore of o er or bull Ing contra r) (date) <br /> ZONING ADMINISTRATOR 40 <br /> .•' N <br /> K) On N N)0101 <br /> fn VI o O V7 O O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 00 0 0 0 0 0 0 <br /> 000000 <br />