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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> y O ^^ <br /> C <br /> OWNER TQ/hQsO� Je f�IanC J / . TELEPHONE 3Ia-3,23- 8"l07!} a <br /> HOME ADDRESS 7.-3j.4 �e 5 �2(J�I�i DCS(-�en L-rL 66-5-6 1 v r <br /> CP <br /> EMERGENCY/FIRE NUMBER ROAD NAME /i L. lS 41 0 1 <br /> LEGAL DESCRIPTION(see tax receipt) y ��yN <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE © ADDITION ❑ PRIVY ❑ lJ p1 <br /> TYPE OF PERMIT(S): Cr <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ a <br /> S.0 <br /> STRUCTURE/ADDITION USE: S fd re 9� — 4' fid dQ <br /> —(Home/C n; Comm tial Business; Bedroom; Deck;etc.) m � <br /> BUILDING CONTRACTOR: ne <br /> ,,aa 11 <br /> m <br /> Lonc7ft..la kdn_ ..Znr_ fit <br /> v <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. p <br /> -A N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <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(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m m IF <br /> n <br /> NORTH(N). y 0 <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 I 'R <br /> 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. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS 5 I <br /> MUST BE SIGNED AND DATED BY THE OWNER. ,o c <br /> v $ <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q <br /> NEEDED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: I <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT DoT <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 /> m � on+ m i M kvm <br /> y <br /> 7. o � <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my [j C <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of n <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognizeM <br /> M <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- l7 <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 m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE �i_ z <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR a 1( �� . ` . <br /> �� KCAL" <br /> is S M o <br /> TOWNSHIP PERMITS MAY BE REQUIRED00 000 <br />