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c Z <br /> Burnett County 7410 County Road K, No. 102, Siren, WI 54872 Office of Zoning Administrator a <br /> APPLICATION FOR LAND USE PERMITS <br /> O y b� <br /> OWNER ,5ITELEPHONE �5 _ <br /> 7 d <br /> MAILING ADDRESS L./ a 3 �-Sa 553 S �O <br /> V / <br /> PROPERTY ADDRESS G) C)Q <br /> aSa3a i3r�, s�� <br /> LEGAL DESCRIPTION <br /> SINGLE FAMILY DWELLING 0 GARAGE/ACCESSORY STRUCTURE 0 ADDITION 0 STAIRS 0 <br /> TYPE OF PERMrT(S): I y 4 <br /> FILLING/GRADING 0 CAMPING UNIT 0 BUNKHOUSE 0 59.692(1V)GAZEBO 0 DECK. ,o <br /> STRUCTURE/ADDITION USE: <br /> 1�e �h /off s co <br /> (Home/Cabin; Co mercial�oussiin/es/s; Bedroom; Deck; etc.) ru� Z <br /> BUILDING CONTRACTOR: 1j we pve C-/L o <br /> n <br /> A PLOT PLAN MUST 8E PROVIDED ON AN 8 Yx X11 SHEET OF PAPER. ANY INCOMPLETE OR ILLEGIBLE PLOT PLANS 0 <br /> WILL BE RETURNED. z o <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (ARU1L OR TOP VIEW) <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS/STRUCTURES (EB)AND ALL NEW C le mU C <br /> BUILDINGS/STRUCTURES (NB),INCLUDING DECKS, PORCHES AND OTHER STRUCTURES, tys7 'O A o <br /> AND INDICATE NORTH (N). a <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A) BUILDING(S)TO ALL LOT LINES, (B) BUILDING(S) <br /> TO CENTERLINE OF ROAD, (C) BUILDING MEASUREMENT(S)TO THE ORDINARY HIGH WATER MARK o 0 <br /> (OHWM) OF LAKE, STREAM OR RIVER AND WETLAND AREAS,AND (D) LOT DIMENSIONS. 5' 'A <br /> 4. SHOW THE LOCATION OF THE WELL(W), SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES C (� <br /> TO BUILDINGS, 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 GT <br /> PLANS MUST BE SIGNED AND DATED BY THE OWNER. c <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MY BE DONE WHEN <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: p O <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT. per` <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. n .� <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. 8 <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER A <br /> SETBACK AREA. <br /> S. ACCESSORY STRUCTURE/GARAGE PERMITS ALLOW FOR PRIVATE RESIDENTIAL GARAGE/STORAGE ONLY. O <br /> NOT TO BE USED FOR HUMAN HABITATION. \ <br /> 6. <br /> 7. <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowledge > E a <br /> and belief R Is true,correct and complete. I acknowledge that I am responsible for Me detail and accuracy of all Information I ^ 2'2 <br /> contained In this application(Including any accompanying schedule)and I further declare that I recognize that this Information I e 8 °e $ <br /> am providing will be relled upon by the County of Burnett Wisconsin In determining whether to Issue a Permit. I further accept all y R y <br /> liability that may be a result of the County of Burnett relying on this Information I am providing In this application. I agree to n <br /> permit county officials charged with admin) g county ordinanc ther authorized person to have access to the above- <br /> described premises at any maw r the purpose of Ins <br /> OWNER'S SIGNATURE <br /> (date) <br /> J10—) <br /> ZONING ADMINISTRATOR IL <br /> - r/l✓) V ft/7 n H' g a Z <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> THIS PERMIT SHALL EXPIRE ONE YEAR FROM DATE OF ISSUANCE d v <br /> Pel'O )T� 4 le-+fel- plafcd up btu J'1Ct wn /UOVaL <br /> U p W N N <br /> 3-a8'-66 �� o <br />