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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -U o 0 <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N � <br /> N <br /> t[ n <br /> OWNER b A L E S SN G TELEPHONE,/7 (CJ _ Mt -1 751 Er ( , <br /> HOME ADDRESS 6 6x 5 9 t 0,64" <br /> � v O�/ , <br /> r � <br /> EMERGENCY/FIRE NUMBER 21 q q6 ROAD NAME u ti c h St �T <br /> LEGAL DESCRIPTION(see tax receipt) <br /> Lot- (P -L('-'+ SQTyiQs ES1 ?� <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑af ADDITION ❑ PRIVY ❑ (�j <br /> TYPE OF PERMIT(S): <br /> FILLING/G'RA11DI__NG ❑ CAMPING UNIT ❑ SUBDIVISION ❑ <br /> 5 <br /> STRUCTURE/ADDITION USE: I'to yam_ o <br /> I� <br /> (Home/Cabin; Commercial Business; Bedroom;Deck;etc.) y� 1 <br /> BUILDING CONTRA TOR: �F C_K l�..l61k � 1.. 7 VVIC rrtKll.C— X� <br /> 2 516 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 6'b X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T - <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 a <br /> 2! Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n � <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m IF 1 1 1 <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 m �3 <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. C�>\ <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. J N 9j <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. c ' <br /> o 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN 0 <br /> NEEDED. ad 0 pXJ� <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z X/ <br /> CONDITIONS OF PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT 1 <br /> ISSUANCE. Q C) <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. W U 1 <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. <br /> 5. <br /> = dam (� gm <br /> 6. 3 o. Ow <br /> m Ci <br /> 7. Z : " MW <br /> o 7� M <br /> : <br /> = 0) 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 IF <br /> all information contained in this application(including any accompanying schedule)and 1 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� m 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 the above described premises at any reasonable time for the purpose of inspection. T <br /> CD <br /> m : <br /> SIGN HERE <br /> 9tll <br /> (s ature of o er or building contractor) <br /> (d te) <br /> ZONING ADMINISTRATOR <br /> N NNNN 0 <br /> (J1 NONN0O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 <br />