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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator' `f'-D o �o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> / �7 <br /> u O <br /> T LL TELEPHONE y/5 b ✓l5 <br /> OWNER GG o t 4 - 4 �Q l^t f V �� �l '? 7 <br /> HOME ADDRESS ,2 7 3 6 2 C6 b y R� N — // ! C <br /> EMERGENCY/FIRE NUMBER ��(� m� ROAD NAME ) <br /> 33--�40 IX <br /> LEGAL DESCRIPTION (see tax receipt) r s j I Q <br /> e <br /> DWELLING/BUILDING ElGARAGE/ACCESSORY STRUCTURE ADDITION U PRIVY U c 0 <br /> TYPE OF PERMIT(S): `CL <br /> c <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ S. <br /> STRUCTURE/ADDITION USE: Y /� 1 g l G N CCN h O ° <br /> (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) m <br /> BUILDING CONTRACTOR: s <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 m <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) In <br /> 'n 0 Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m ;a2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m on <br /> NORTH(N). W <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 I Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. ° <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO Q <br /> BUILDINGS,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 5. <br /> MUST BE SIGNED AND DATED BY THE OWNER. ° <br /> o � � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q ° <br /> NEEDED. / <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. P <br /> CONDITIONS OF PERMIT: <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 �j <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. _ q <br /> 5. d(L (C *5m�D mvatly �_ <br /> 6. m cm <br /> Z : m N <br /> 7. y <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my r C <br /> knowledge and belief it is true, correct and complete. 1 acknowledge that I am responsible for the detail and accuracy of ti: o B <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize .XS(pI J : m L7 m <br /> : l7 <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 7T;, 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 v <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. <br /> M <br /> SIGN HERE nSHIP <br /> (sig atug contractor) (date) <br /> ZONING ADMINISTRATORTMITS MAY BE REQUIRED (Yo 0 0 0 0 0 0 <br />