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(tn <br /> a, / pzrmI t -tv UJ e bder fiddve-ssl <br /> Burndtt County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator 0 o <br /> CD APOLICATION FOR LAND USE PERMITS 3. <br /> /fome A 691- 7776 -;L7*0 C <br /> OWNER Rot, SUF- T'oNNgOrJ TELEPHONE CA&Urfk -7j!5 -g46-7617 <br /> HOME ADDRESS .I o 4 a I�LrRM Avj-, /VI A PLFWD00 i MA), <br /> 69j< <br /> 0 <br /> 0 <br /> EMERGENCY/FIRE NUMBER ROAD NAME `J' TG B$ R b , ~ <br /> LEGAL DESCRIPTION(see tax receipt) A 1 1 M14 ED <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION 9L PRIVY ❑ CO 0 <br /> C <br /> TYPE OF PERMIT(S): ) Cr <br /> FILLING/G <br /> RA <br /> DI <br /> NG <br /> 0 CAMPING UNIT 1:1SUBDIVISION ❑ / �/ m <br /> STRUCTURE/ADDITION USE: �C�JI�'A to/` T��4(M o <br /> (Home/Cabin; Commercial Business; Bedroom;Deck;etc.) m <br /> BUILDING CONTRACTOR: PET-C PLS IJ AVS — &79- AX9-7 is S <br /> M <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCO ETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T o <br /> �+ v Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 'p <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C Ci <br /> NORTH(N). N G <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. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO d <br /> BUILDINGS,ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. ` 64 <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. m °o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q <br /> NEEDED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. P <br /> b <br /> CONDITIONS OF PERMIT: c (� <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. 1 f U <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY 1 <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> ;a -0 fir O : M <br /> 7. o 1 <br /> m: i 70 <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my Zi c c <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of o <br /> all information contained in this application(including an accompanyingschedule)and I further declare that I recognize m m <br /> PP ( 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 m' <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other ko m <br /> authorized person to have access to ove Pescribed premises at any reasonable time for the urpo of Inspection. 1 <br /> n . <br /> m <br /> a� Q <br /> SIGN HERE 1v� <br /> (signatu o wner or building contr c r) (date) <br /> 1 <br /> ZONING ADMINISTRATOR v+ <br /> Nut IN) NNN <br /> N 0O N p1OO <br /> WNSHIP PERMITS MAY BE QUIRED i 000000 <br />