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00 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator Z <br /> APPLICATION FOR LAND USE PERMITS t <br /> r0 <br /> w 0 <br /> OWNE rel' IIT �/ToSY ��N� G f� TELEPHONE 7/ - 4:� J-mss 5` us � J <br /> HOME ADDRESSZ�� P 5 $ O <br /> a r N A V� �P !� ��L— /Lt`<l��✓N ✓J/u l 5�l P C i� 0 <br /> r � <br /> EMERGENCY/FIRE NUMBER L1 <br /> ROAD NAME -rSrje C,. y-/ o <br /> LEGAL DESCRIPTION(see tax receipt) <br /> Se c IV m <br /> /S twoTYPE OF PERMIT(S): DWELLING/BUILDING�GARAGE/ACCESSORY STRUCTURE A y 0 <br /> DDITION v <br /> CL <br /> 5. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0' <br /> STRUCTURE/ADDITION USE: * �^j V -� <br /> �trn inA Ca�i�n -�' u <br /> d(Home/Cabin;Commercial Business;Be oom;Deck;etc.) 'a � <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T _ <br /> DIRECTIONS FOR PLOT PLAN DAWING• (AERIAL OR TOP VIEW) <br /> 0 <br /> r1 ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. T v z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m S <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, <br /> STREAM OR RIVER. z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS,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 PLANS <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> m o 1 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> ISSUED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT 1 <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 /> 5. <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. C-) <br /> 6. ;U 'm m 4 <br /> .� 3 1 ' It <br /> 7. R a <br /> o ' � <br /> � 1 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to theCO <br /> best of my Zg `: : A <br /> M <br /> knowledge and belief it Is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of (y mC <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize 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- E E i i <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 fa ' <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m , <br /> SIGN HERE �Z 77 <br /> (signature own di contractor) date J <br /> 1 ) <br /> ZONING ADMINISTRATOR 7m m r ` p <br /> fA N H Pi 03 <br /> N p p p Nn p p <br /> [il N O NP1CG <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />