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V'2- pit"T <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> i,9 441'91& <br /> OWNER�GI�IJ/ �� "��I� E� /iGf[/ TELEPHONE //S CU 1O <br /> ; W <br /> HOME ADDRESS <br /> /W'1!9 tie , �cQ /� �.ODo/1,1�' w1� / v W P <br /> r � <br /> ) <br /> EMERGENCY/FIRE NUMBER /gg� ROAD NAMe o <br /> r <br /> LEGAL DESCRIPTION(see tax receipt) '® 1 9 y to Z-0 r _C�/ C m <br /> 0 <br /> et. <br /> DWELLING/BUILDING 0 GARAGE/ACCESSORY STRUCTURE E ADDITION El PRIVY El <br /> TYPE OF PERMIT(S): Q <br /> FILLING/GRADING ❑ CAMPING UNIT 19 UBDIV ION <br /> STRUCTURE/ADDITION USE: 'Orel-< ,� 0 <br /> (Home/Cabin;nCommercial Business; Bedroom; Deck;etc.) m d <br /> BUILDING CONTRACTOR: l` — �4/ �N/F OIL) ' <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/a X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 0 <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <br /> NORTH(N). fn o <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 ` Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. o <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. 1 <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. ri <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. o o <br /> O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q °, <br /> NEEDED. <br /> i c <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z0 1 <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT I <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 THE REQUIRED WATER �r <br /> SETBACK AREA. L �] �}�, <br /> \ /� 6r- <br /> �C�� y Ocg <br /> 6. (D vnyya ' 3 <br /> D m C m . o 0 <br /> 7. o N 1D <br /> y : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c C <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize ,r m m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- *1 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 m <br /> authorized person to have access to t4e above described premises at any reasonable time for the purpose of inspection. <br /> -n : <br /> m : <br /> CD <br /> : �- O <br /> SIGN HERE ^ <br /> (signatur f ner or building tr �torl)^ (date) '(�1 <br /> ZONING ADMINISTRATOR <br /> N N V1NNN (T <br /> u7 VtO (T fT00 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 <br /> 0000000 <br />