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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of <br /> APPLICATION FOR LAND USE PERMITS Zoning Adminls rator o 0 <br /> OWNER <br /> '✓(1 /J(.C-L�� / /LE/N�-tX.i[l•J-/ �J f/ / �I�TELEPHONE �� U[J r'�"• Q 9,\ 00 <br /> HOME ADDRESS <br /> O <br /> f <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) L J1 <br /> TYPE OF PERMIT(S): DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ ❑ �i 0 <br /> PRIVY <br /> FILLING/GRADING ❑ CAMPING UNIT <br /> ❑ SUBDIVI ION <br /> STRUCTURE/ADDITION USE: <br /> /l� � <br /> S y <br /> O <br /> (Home/Cabin; Commercial Business Bedroom; eck; etc.) c� <br /> BUILDING CONTRACTOR: ` <br /> Cn <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR v <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 3 <br /> m <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O <br /> it N <br /> O m <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. -n p Z ` <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). m � t <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 ° <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. Z <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO P <br /> 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 PLANS t� <br /> MUST BE SIGNED AND DATED BY THE OWNER. 0 1 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONDITIONS OF PERMIT: Z 1 <br /> 0 <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 /> 6. y <br /> D O M <br /> 00 RID f m <br /> 7. v 3 am �c ° Zl 1 <br /> D C y N O 3 <br /> Z m 10D0 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the bestof my A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m <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 d l7 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m : <br /> m : <br /> SIGN HERE m <br /> (signature of ow er building contractor (date) <br /> ZONING ADMINISTRATOR ~ <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />