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C O <br /> Burnett County 7410 County Road K, No. 102, Siren, WI 54872 Office of Zoning Administrator <br /> APPLICATION FOR LAND USE PERMITS <br /> OWNERL� ��tc TELEPHONE <br /> MAILING ADDRESS <br /> PROPERTY ADDRESS �l <br /> (—/ -//� \� <br /> LEGAL DESCRIPTION <br /> TYPE OF PERMIT(S): SINGLE-FAMILY DWELLING ❑ ADDITION DECK❑ GARAGE/ACCESSORY STRUCTURE 0 <br /> BUNKHOUSE ❑ 59.692(1V)GAZEBO ❑ STAIRS ❑ FILLING/GRADING ❑ CAMPING UNIT ❑ <br /> COMMERCIAL BUILDINGG ❑ COMMERCIAL ADDITION ❑ COMMERCIAL ACCESSORY STRUCTURE E) o <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) <br /> BUILDING CONTRACTOR: n <br /> O � � <br /> A PLOT PLAN MUST BE PROVIDED ON AN B V/z X11 SHEET OF PAPER. ANY INCOMPLETE OR ILLEGIBLE PLOT PLANS G o_ <br /> WILL BE RETURNED. ,I <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (ARIAL OR TOP VIEW) o. <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. O <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS/STRUCTURES (EB)AND ALL NEW <br /> BUILDINGS/STRUCTURES (NB), INCLUDING DECKS, PORCHES AND OTHER STRUCTURES, v <br /> AND INDICATE NORTH (N). N Z <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A) BUILDING(S)TO ALL LOT LINES, (B) BUILDING(S) ° <br /> TO CENTERLINE OF ROAD, (C) BUILDING MEASUREMENT(S)TO THE ORDINARY HIGH WATER MARK w2, <br /> (OHWM) OF LAKE, STREAM OR RIVER AND WETLAND AREAS,AND (D) LOT DIMENSIONS. p <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD (DF),AND ALL DISTANCES <br /> TO BUILDINGS, ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER, CONTRACTOR, ETC.,THE <br /> PLANS MUST BE SIGNED AND DATED BY THE OWNER. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MY BE DONE WHEN <br /> NEEDED. <br /> � 1 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: ,- <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. n <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC., ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. lfl <br /> 5. ACCESSORY STRUCTURE/GARAGE PERMITS ALLOW FOR PRIVATE RESIDENTIAL GARAGE/STORAGE ONLY. <br /> NOT TO BE USED FOR HUMAN HABITATION. <br /> 6. <br /> Z ^ qd Dnnn py>0 -0 <br /> " n 2330-=- <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my <br /> knowledge and belief It is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all <br /> Information contained In this application(including any accompanying schedule)and I further declare that i recognize that this <br /> Information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to Issue a permit. I v a cw y <br /> further accept all liability that may be a result of the County of Burnett relying on this information I am providing in this % d,ti- " 41 <br /> application. I agree to permit county officials charged with administrating county ordinances or other authorized person to have c � � o o � `? .r. <br /> access to the above-described premises at any reasonable time for the purpose of Inspection. <br /> D � 0000 <br /> OWNER'S SIGNATURE >a m n tin O <br /> (date) o ei c,F, ° 3 a = Z <br /> ZONING ADMINISTRATOR <br /> i+ Fn <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> THIS PERMIT SHALL EXPIRE ONE YEAR FROM DATE OF ISSUANCE <br /> � �, 00000 <br /> {�{e✓a (-f- d- ie C i'( %2z�l Lit-) /40 �r/l <br />