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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o --nz>o <br /> APPLICATION FOR LAND USE PERMITS <br /> N <br /> OWNER Jerry & Donna Koss TELEPHONE (651 ) 480-85523 0 <br /> 1121 Park bane Hastings, MN 5503 Q <br /> HOME ADDRESS r <br /> 28738 County Rd. F Danbury, WI <br /> EMERGENCY/FIRE NUMBER ROAD NAME a, <br /> LEGAL DESCRIPTION(see tax receipt) W1/2 S1/2 N1/2 NW NE l 7 — q i) ti <br /> m <br /> a <br /> DWELLING/BUILDING On <br /> ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION © PRIVY ❑ N <br /> c <br /> TYPE OF PERMIT(S): <br /> LX <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ S. <br /> T. <br /> STRUCTURE/ADDITION USE: Home / Cabin <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) c <br /> BUILDING CONTRACTOR: Self <br /> e � <br /> V <br /> M <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 H n <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) "n o. d <br /> in 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 <br /> NORTH(N). ` 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m C/ <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF o <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 <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 .S� > >. <br /> MUST BE SIGNED AND DATED BY THE OWNER. 0 ! <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN a <br /> NEEDED. <br /> �. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. I <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ' <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. a 30 I HCl <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. r✓( <br /> CD m <br /> ayyo� 3 <br /> 6. , . <br /> Z : G <br /> 7. O N i M <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 4� A <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of W c <br /> all information contained in this application(including any accpgt ying schedule)and I further declare that I recognize M <br /> ro m : m <br /> that this information I am providing will be relied upon by the $,urneft Wisconsin in determining whether to is- m O <br /> sue a permit. I further accept all liability which may be a,re' �o aurneft relying on this information I am m <br /> providing in this application. I agree t permit county o, ials cha i tering county ordinances or other m <br /> authorized person to have access tot above described emises at any r n *t <br /> rrte for the purpose of inspection. -n <br /> m <br /> SIGN HERE <br /> p S 76-et> <br /> gnatur f o er or building con (date) <br /> ZONING ADM4 VTRATOR 1 <br /> tq "0 "" M01 <br /> 610 °� .c1A 44 4ft <br /> Ni, *0i 'O� oo <br /> T NSHIP PERMITS MAY BE REQUIRED <br /> 1,3610 <br /> 3 8'0 0 0 0 0 0 0 <br /> 0000000 <br /> I� ��' iQ t Cr <br />