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Bfrrnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -U G) z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r <br /> rn °. <br /> N <br /> C <br /> OWNER �QUe � 1� Gfo�aJ� TELEPHONE6Og-78'3. 7373 0 <br /> o <br /> v / _ m <br /> HOME ADDRESS I Z Z �p�wa��—Trate �f�g l Sli Kl� W r S(/ �yv <br /> m <br /> EMERGENCY/FIRE NUMBER a 7TO ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) oLp- '1 s— qo _ 'S m <br /> � 0 <br /> y <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION Li�-PZ ❑ <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ a , <br /> STRUCTURE/ADDITION USE: / f1`Gt�_ o <br /> -(Home/Cabin; Commercial Business; Bedroom; Deck;etc.) rn I h <br /> BUILDING CONTRACTOR: <br /> v1 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p a <br /> T Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n m p <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m �? <br /> NORTH(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)OF Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. "` o <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. I <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 0),-z36.NO <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. �� o <br /> v � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN Cr <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z Q� <br /> CONDITIONS OF PERMIT: P (��J <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 W <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER QG <br /> TJREA. <br /> 5. . <br /> CD W v <br /> 6. � � Bom � 0v, <br /> 0 S.a CeNN0S 3 <br /> 7. Z : m CD fc � <br /> / ;jj ` <br /> — w : m <br /> I declare that this application (including any accompanying schedule) has b eXAiiiined by me and to the best of my <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am reso6ri ii¢le for the detail and accuracy of <br /> all information contained in this application(including any accompanying ule)and I ttirther declare that I recognize od m m m <br /> that this information I am providing will be relied upon by the County of Burn tt IsConsin in'determining whether to is- ti O <br /> sue a permit. I further accept all liability ch may be a re my of9Buih yIng on this information I am <br /> providing in this application. 1 agre a it coup s charge dminis county ordinances or other 1CD <br /> authorized person to have acce h ov ed premises at an n time for the purpose of inspection. T <br /> M <br /> SIGN HERE <br /> Ignat a of owner ui g contractor) (date) - <br /> ZONING ADMINISTRATOR <br /> N(T NN <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 o <br />