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Burnett County 7410 Co. Rd.K, No. 102,Siren,WI 54872 Office of Zoning Administrator M <br /> APPLICATION FOR LAND USE PERMITS <br /> c <br /> S � TELEPHONE qOWNER � tz \XN m <br /> i3 <br /> HOME ADDRESS c:P,5 I [ ct <br /> EMERGENCY/FIRE NUMBER 05–, 72 ROAD NAME LAS✓f E �) <br /> I � <br /> LEGAL DESCRIPTION(see tax receipt) w J J 1—`fFCc <br /> 0 <br /> at <br /> TYPE OF PERMIT(S):DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE ADDITION rr <br /> a. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION n'�/ <br /> m <br /> STRUCTURE/ADDITION USE: n� 00tZ `�n�T2y QO2c31\7, — 40'm <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR T z J <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. X <br /> c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) n n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE.AND <br /> $ <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE N �. e <br /> NORTH(N). <br /> 3 CEN ERSHOW LINE OF ROAD, CE BUENSINS IN FET ILDING(S)NG(SF THE O MEASUREMENT UTOOTHE(ORDINARY HIGH WATER MARK TO ALL LOT LINES, (B) i(OHWM)OF LAKE, m v <br /> Z <br /> 0 <br /> STREAM OR RIVER. <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 /> 64 <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS o <br /> R o <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE C S <br /> ISSUED. <br /> Z 1 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. P <br /> CONDITIONS OF PERMIT: <br /> I. 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 75 FEET OF THE OHWM OF LAKES, <br /> PONDS,RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. 3niO Com <br /> v N N d <br /> 6. wmo to <br /> o ` A <br /> 7. =cnm <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my E c <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of CL <br /> ' m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognizeM <br /> t7 <br /> that this information I am providing will be relied upon by the County of Bumeft Wisconsin in determining whether to is- m , <br /> sue a permit. 1 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 o <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. W <br /> m : <br /> SIGN HERE (date) <br /> signaturo ner or building contractor) <br /> h <br /> ZONING ADMINISTRATOR w w fn`)H iA <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 0000000 <br />