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4 mu <br /> low <br /> 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 /> N O^ <br /> N <br /> C <br /> OWNER � "�� 7 TELEPHONE (V�� CV 7� <br /> 0 <br /> m <br /> ) / r 0 <br /> HOME ADDRESS /0800 /o'�Y" F�a�e / ���Q /PIS°. <br /> r(,) 1 <br /> l' <br /> EMERGENCY/FIRE NUMBER ��� `��� ROAD NAME 6tilJb1.�. y�� J! 0 <br /> 1 <br /> Nus I� N w ' I .5 3�l i 4v N /� 11✓ <br /> LEGAL DESCRIPTION(see tax receipt) <br /> t H <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIW ❑ <br /> TYPE OF PERMIT(S): n <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ < (-b <br /> STRUCTURE/ADDITION USE: I I1� <br /> d (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) m <br /> BUILDING CONTRACTOR: i f'PYI iCD <br /> v <br /> v <br /> I <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR -n <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. p <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O n <br /> n <br /> T Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. mm p <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> C NORTHo <br /> 3. SHOW DIMENSIONSIN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF , Z <br /> Z <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 Q C> <br /> BUILDINGS,ROADS,LAKE, LOT LINES. <br /> S. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. IN <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS <br /> MUST BE SIGNED AND DATED BY THE OWNER. f <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN ° <br /> NEEDED. ) <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o W <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. (JV <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 /> CD m r 0 O Da :E M <br /> d Fm <br /> 6. N o <br /> a y N a x <br /> M C: <br /> N N o <br /> 7. o -n' A <br /> m <br /> 1 declare that this application (including any accompanying schedule) has been examined by me and to the best of my Q) G7 C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of o 2 <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize <br /> M <br /> that this information 1 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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinan es or other <br /> authorized person to have access to the above described premises at any,re fol f'n pection. T <br /> SIGN HERE <br /> (signaturl ownerorbuilding contractor) AY _ G�UI(date) 1 <br /> ZONING ADMINISTRATOR / A G U <br /> BUI tr .a i I�r:rUN i Y R' <br /> TOWNSHIP PERMITS MAY BE REQUIRED ZoIJi�lCa a aq <br /> d <br />