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&2GZwZf <br /> 6urnett'County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 o o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> y O <br /> OWNER TELEPHONE �— ' `\ <br /> �.4,wel ( lPn�4nir14 7/�-(0�� a ii'3 0 <br /> i , � m <br /> jZI <br /> HOME ADDRESS G <br /> �T <br /> EMERGENCY/FIRE NUMBER 41 I ed L� ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) 0.`= <br /> DWELLING/BUILDING ® GARAGE/ACCESSORY STRUCTURE.2 ADDITION ❑ PRIVY ❑ _1Z in <br /> , <br /> TYPE OF PERMIT(S): a i <br /> c <br /> FILLING/GRADING ❑ CAMPI UNIT ElSUBDIVISION ❑ N <br /> 5. <br /> STRUCTURE/ADDITION USE: 01'11 NI aYx2q 0 <br /> / ( ( me/ abin;Ptfmmercial Business; Be oom; Deck;etc.) or <br /> BUILDING CONTRACTOR: <br /> e � <br /> v <br /> M <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR n '3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 <br /> N <br /> p C <br /> T Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <br /> n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m3 <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. c <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. V <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. ry <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS Do� 4 <br /> MUST BE SIGNED AND DATED BY THE OWNER. m o <br /> ( off <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN Cr <br /> NEEDED. <br /> O <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. zc <br /> CONDITIONS OF PERMIT: 1 <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. D1. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY W <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN THE REQUIRED WATER O <br /> SETBACK AREA. <br /> 5. <br /> 6. � a� z <br /> a m c a . Z <br /> 7. Z y ;aCn <br /> o : <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of myrrw c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of vt W <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m , m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- v <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 E <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. T <br /> q m <br /> SIGN HERE <br /> (signature o wner or b ntractor) (date) <br /> ZONING ADMINISTRATOR to <br /> lift 169 <br /> T NSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 <br />