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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> VT 0 l <br /> N <br /> C <br /> fD <br /> OWNER 1k1 " a �� � Q ,,JI� TELEPHONE 44 <br /> w <br /> 1 i, <br /> HOME ADDRESS CD`�� "� CLD /J � ,V�j�/� I O <br /> CD <br /> EMERGENCY/FIRE NUMBER DL-13 13r1 ROAD NAME 1�av r~� �� "t\0 <br /> i <br /> LEGAL DESCRIPTION (see tax receipt) La CSSt V a cn <br /> DWELLING/BUILDING 11 ON GARAGE/ACCESSORY STRUCTURE ❑ ADDITI ❑ PRIVY El <br /> TYPE OF PERMIT(S): cn <br /> c � ' <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ a <br /> STRUCTURE/ADDITION USE: <br /> (Home/ bin, Commercial BusihW, Bedroom; Deck; etc.) co <br /> BUILDING CONTRACTOR: ��_ <br /> T <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 6Ya X 11 SHEET OF PAPER. ANY INCOMPLETE OR CD <br /> 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 'n — <br /> O r tl <br /> T7 N V" <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <br /> 'T <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. T z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE n o <br /> M <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TOM v 0 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. Z <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 /> S. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N Q <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. 22. <br /> o Cj <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN o <br /> NEEDED. T (1 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: 9 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT I <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. pQ <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> ;uC) � DODO -V <br /> (D C N y COD B COD 01 a= <br /> O j 3 <br /> 7. Z N O <br /> O T1`G M <br /> M <br /> I declare that this application (including any accompanying schedµle) has been examined by me and to the best of my �j A <br /> knowledge and belief it is true, correct and complete. I acknowl 1,11 I am responsible for the detail and accuracy of m 0 m <br /> all information contained in this application(including any acc dule)and I further declare that I recognize <br /> that this information I am providing will be relied upon by the o r cousin in determining whether to is- m <br /> sue a permit. I further accept all liability which may be a res the 1 m <br /> Y relying on this information I am <br /> providing in this application. I agree to permit county off! I charged wit I unty ordinances or other <br /> authorized person to have access to the above described p es at reasons I, rpose of inspection. m <br /> -n <br /> r1 m <br /> SIGN HERE eta U E» <br /> (sig atu a of o r building contractor) (da ) <br /> ZONING ADMINISTRATOR 4>.()ACO� n <br /> TOWNSHIP PERMITS MAY BE REQUIRED (� — <br /> ;116 IIV C4& � <br />