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Burnett(.. unty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator � ° <br /> APPLICATION FOR LAND USE PERMITS3 ` <br /> (� <br /> n <br /> -1-13 g' 9 � �Nw� r \IXJ <br /> (cSl- " S <br /> OWNERT- ��AS 1`O✓�✓>l+� yU4--V�`�Qf�.TELEPHONE (o l2^(�SiS - S-37-46 (Cgil /\ <br /> HOME ADDRESS 1� c 'S+- PC"-...k, SS109 <br /> A i 0t m <br /> EMERGENCY/FIRE NUMBER A-Pph e666/// F[}r ROAD NAME <br /> C71 <br /> LEGAL DESCRIPTION(see tax receipt) Ca C>� <br /> c <br /> DWELLING/BUILDI GARAGE/ACCESSORY STRUCTURE ❑ ADDITION El PRIVY 0 o) ° <br /> TYPE OF PERMIT(S): a <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ ySUBDIVISION ❑ 5 <br /> STRUCTURE/ADDITION USE: C��J-+� O'S J� :R>a`—� <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) m <br /> BUILDING CONTRACTOR: 5i <br /> 1 <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. p O <br /> c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 0 <br /> o Z <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 C n <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)OFo <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. Ll <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 /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS W <br /> MUST BE SIGNED AND DATED BY THE OWNER. I o Q <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q ° I✓ <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT Q \ 1 <br /> ISSUANCE. +v . <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 <br /> 5. /lip /,�AREA. <br /> 7t7) ` e)' YI G r a l P edge-, <br /> co m <br /> 3 ° <br /> � D f� C N ° 7 3 <br /> . J <br /> 7. OZ i T'< 1 <br /> Cn ; <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my a Gi C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of o E' <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 00 O <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 m <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other 3 <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m : <br /> Q <br /> SIGN HER <br /> (signature of o ne or building contr c (date) 1 <br /> ZONING ADMINISTRATOR <br /> 040En40401.0� <br /> N N (IiNNU1N <br /> N Ut OfliN00 <br /> TOW HIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0000000 <br />