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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v G) Z <br /> APPLICATION FOR LAND USE PERMITS 3 ° <br /> r <br /> rn o <br /> OWNER jqnnQ. 1 )0,, (: K�IQ <br /> TELEPHONE �[y5i)�77� 400 4I_ o <br /> HOME ADDRESS iq ven o 4h t I 66 log v Al <br /> EMERGENCY/FIRE NUMBERn r <br /> I '1$ ROAD NAME '1�o <br /> LEGAL DESCRIPTION(see tax receipt)T40 N, R 1 4 I O J /� <br /> W, c T I , 3e,oorl #C2A i r� <br /> TYPE OF PERMIT(S): <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE El ADDITION QUI PRIVY y❑ � � <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ a <br /> scree e S. <br /> d in cIQoK N <br /> STRUCTURE/ADDITION USE: o <br /> (Home/Cabin, Commercial Business; Bedroom; Deck;etc.) Cl) <br /> BUILDING CONTRACTOR: 1(t Q C(�nS`I'! I t !�-} 1 <br /> � —Incl., E <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR N <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T 3. <br /> i ` <br /> DIRECTIONS FOR PLOT PLAN DRAWING• (AERIAL OR TOP VIEW) O <br /> n a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. T Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m �? A <br /> NORTH(N). C n <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 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. Z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO P <br /> BUILDINGS,ROADS, LAKE, LOT LINES. <br /> 6. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. Q <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 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a 0 ` <br /> NEEDED. 4 <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 Q� <br /> ISSUANCE. ("^1- <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 <br /> SETBACK AREA. �p <br /> 6. �. /� rtS- l`r9/0l)- � �`�- /✓1G?L!� pL,2'�%�" <br /> (G�IIdCJ, m 3 a. CT <br /> � �o Z <br /> C.0 CT <br /> 7. V <br /> N <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 21 c <br /> m <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m I, C <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- <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this information 1 am <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> I - <br /> SIGN HERE ,-Jd*—t6 gr Cr1 co <br /> ss <br /> Is nature of owner o b ilding contractor) (date) <br /> ZONING ADMINISTRATOR O <br /> wfnCArir)CA0' <br /> �'� N9 N r)CA 01 <br /> 3 per. �o�� oo <br /> TOWNSHIP PERMITS MAY BE REQUIRED �I��' I <br />