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cr� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator-0 o <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N o <br /> N <br /> C <br /> OWNER �CI���, <br /> . d �� r r� ��� a <br /> TELEPHONE � 7 y� <br /> HOME ADDRESS 2.52Z (enc (LJr-c�or\ �C)Y'�Q V/� a. `J-tqc) r (� <br /> o <br /> EMERGENCY/FIRE NUMBER SZ Z ROAD NAME )) <br /> --C� 1 n <br /> LEGAL DESCRIPTION (see tax receipt) (� vl 3�-I-/ m <br /> y <br /> TYPE OF PERMIT(S): DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE � ADDITION— <br /> SANITARY— <br /> DDITION SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION ° <br /> STRUCTURE/ADDITION USE: r mrn 1 <br /> (Home/Cabin; Commercial Business; Bedr m; eck; etc.) -a <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR n 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. p <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O a <br /> 'r v Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. a m X <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m �? <br /> NORTH(N). y 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A) BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m v <br /> CENTERLINE OF ROAD, (C) BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> 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 BUILD- C� <br /> INGS, ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <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. o o (, ) <br /> o � W <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE S. <br /> ISSUED. 0 <br /> I <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. p a <br /> CONDITIONS OF PERMIT: c` , <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 /> 6. v m C 0, V, 0 <br /> c' m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 7 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 0 <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize CD m M <br /> 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 o <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 <br /> (signature of o er or building contractor) (date) (� <br /> ZONING ADMINISTRATOR <br /> cn cn tnwwF»�' <br /> N N(T NN (n (n <br /> V7 O 01 (l, O O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0000000 <br />