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Burnett County 7410 Co. Rd:K, No. 102, Siren,WI 54872 Office of Zoning Administrator -V a Z <br /> AOPLICATION FOR LAND USE PERMITS 3. <br /> IIc I5 up -rft, Grid A 4,✓h, N <br /> ��©e�E ��R(S yN 6tz <br /> TELEPHONE 7 3 ► 9 a -� <br /> OWNER <br /> MAI` a <br /> HOME ADDRESS Z1 Z 5)LV F—a k IL 4,ST A NToom Y V1 L.L.¢G,E(MAS) AI <br /> o <br /> EMERGENCY/FIRE NUMBER S Z ROAD NAME <br /> Tb L+)AI Opt Z4- <br /> LEGAL DESCRIPTION(see tax receipt) 40T I ' P 7 ©F �.— 1b�A) �,q(S m <br /> W 0 <br /> a <br /> DWELLING/BUILDING 54 GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ Cl) o <br /> TYPE OF PERMIT(S): `a <br /> FILLING/G'R1ADING UNIT ❑ S I ❑ o; <br /> STRUCTURE/ADDITION USE: t'FGI•J� K�2 �C (W o. <br /> (Home, / <br /> /(Cabin; Comm 'cial`Busin/ess; � <br /> Bedroom; Deck; etc.) r <br /> BUILDING CONTRACTOR:�f jit'LI Ktf— "I'/A LS ��} �OAAk,S <br /> +OA Li: <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'/z X 11 SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O <br /> q <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O m <br /> n a <br /> MZ <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <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 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO \O <br /> BUILDINGS, ROADS,LAKE, LOT LINES. ) <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. I\n, <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS Voll t' <br /> MUST BE SIGNED AND DATED BY THE OWNER. / o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN S C <br /> NEEDED. 0, S <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <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. O <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY Q, <br /> PERMITTED. F <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER V I <br /> SETBACK AREA. <br /> 5. <br /> 6. m � 3aNW—ac t <br /> C:S <br /> 7. :o <br /> o . <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my (j c p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracyof o ?? c <br /> all information contained in this application(including any accompapyjng schedule)and I further declare that I recognize m m m <br /> that this information I am providing will be relied upon by the Co,tko pf_84mett Wisconsin in determining whether to is t7 <br /> sue a permit. I further accept all liability which may be a result of th tjnbj�f Burnett relying on this information I am p d <br /> providing in this application. I agree to permit county officials charged with iidmirijstering county ordinances or other m <br /> authorized person to have access to the above described premises reasonable Urns for the purpose of inspection. <br /> -n :CD <br /> 2040 -�- Ind <br /> SIGN HERE '' � � • <br /> (signaturof r or building contracto (date) (� <br /> ZONING ADMINISTRATOR Fn <br /> �to to v+v+to f» <br /> N N (INN(lN <br /> N NOUt VtOO <br /> TO NSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />