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_ (�-n cx.)—gyp <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - <br /> APPLICATION FOR LAND USE PERMITS <br /> OWNER TELEPHONECL <br /> CDHOME ADDRESS <br /> ti 1 <br /> EMERGENCY/FIRE NUMBER I ROAD NAME F-t 4 //'1-ej- Pd 0 <br /> ,./ <br /> LEGAL DESCRIPTION(see tax receipt) f- 3 C� V / P /7 -/,6 It <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE El ADDITION ❑ PRIVY ❑ <br /> e <br /> TYPE OF PERMIT(S): ur 0 <br /> C <br /> FILLING/GRADING [ICAMPING UNIT Cr <br /> ❑ SUBDIVISION q <br /> STRUCTURE/ADDITION USE: d <br /> (Home/Cabin, ommercial Business; Bedroom; Deck;etc.) m <br /> BUILDING CONTRACTOR: <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 6'/:711 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. _n - \\ <br /> O w V <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T a ' <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. T 0 1 Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m \ <br /> NORTH(N). m 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 • <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 c <br /> BUILDINGS, ROADS,LAKE, LOT LINES. -(o, <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. c <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHENq 0 <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: P (� <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. W <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. D <br /> 6. <br /> OM <br /> CD m <br /> m C 0 o <br /> 7. Z a �Q �ro � <br /> o 7J <br /> I declare that this application (including an accompanyingschedule has been examined by me and to the best of my p <br /> PP ( 9 Y ) <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m c <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize mm <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- ki <br /> m p <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 ordinances or other m , <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of Inspection. <br /> m <br /> m : <br /> SIGN HERE <br /> (signature f owner or building contr r) (date) <br /> ZONING ADMINISTRATOR - <br /> NNNNfrIN <br /> GI O U1 V7 O O <br /> OWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />