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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -' 0Z <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> UT O <br /> OWNER jQ C . — P"(2KISS()erTELEPHONE&I -J— <br /> /'� / � /' /�,� m K� <br /> HOME ADDRESS /6 9L� ,�QCl�, 17/2!/�Pti(011�l/�' 7V` /rl�n7� O <br /> i r <br /> EMERGENCY/FIRE NUMBER ROAD NAME �n hQL& o <br /> LEGAL DESCRIPTION(see tax receipt) �cn <br /> P. I(olut town Cf Mand ) ,gurncf} C)a01j1-y ) <br /> DWELLING/BUILDING 1:1GARAGE/ACCESSORY STRUCTURE 1:1 ADDITION LPRIVY ❑ O <br /> N o <br /> TYPE OF PERMIT(S): v <br /> FILLING/GRADING ❑ CAMPING UNIT SUBDIVISION ❑ 9: rY1 ' <br /> STRUCTURE/ADDITION USE: � <br /> (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) rn <br /> BUILDING CONTRACTOR: m <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOM LETE LOR p ' I T 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. SSI'✓ M r l I l p <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o W <br /> -n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 3 m �0 <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). N o <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m <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. P <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. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <br /> 0Z <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS 1 <br /> MUST BE SIGNED AND DATED BY THE OWNER. f It- <br /> NOTE: <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN <br /> NEEDED. C <br /> t <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. 0 <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT \ <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 <br /> SETBACK AREA. <br /> 5. _ <br /> _ ( � CD 0CDCD aFm <br /> 6. m < 3 a m 0 ° <br /> -o mIWD <br /> 7. p y < <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my / , r C) c C <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of Q <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m mm <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 I 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 t the above described premises at any reasonable time for the purpose of inspection. CDT <br /> I a - <br /> SIGN HEsc I o , 'C O� <br /> (sign re of own wilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> c <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />