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t&" <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o <br /> 0 <br /> APPLICATION FOR LAND USE PERMITS 3. < <br /> N <br /> OWNER Sf��rn J�/QM F�4 TELEPHONE�r�/933 — /acs (,t�, o a <br /> /y� �a c- <br /> HOMEADDRESS ��6� 0)C6Uri� GAn� /L %Ql//I A's/ ssO 7 7 v <br /> r � <br /> _, 0 <br /> EMERGENCY/FIRE NUMBER ROAD NAME /� -A. <br /> Lo-f 31 CSM l/o/ P Zoe 9` a03 t <br /> LEGAL DESCRIPTION(see tax receipt) Gov Lef Z -5Ec PC 7 h, ► U c� <br /> o �+` <br /> DWELLING/BUILDING 19 GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY y � <br /> TYPE OF PERMIT(S): c <br /> FILLING/GRADING ❑ CAMPING UNITE] SU,B�DIVII ION ❑ 5 <br /> STRUCTURE/ADDITION USE: C4&1) 4i /�h U(.1/ 0 <br /> o' <br /> (Home/Cabin; Commer al Business; Bedroom; Deck;etc.) ur <br /> m <br /> BUILDING CONTRACTOR: n kin E/ <br /> CDv <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. -' <br /> O <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O c � - <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 0 <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). y o <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. c <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. d <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 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q 0�. � <br /> NEEDED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z ) <br /> CONDITIONS OF PERMIT: G 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. Q <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY rv/ <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. / <br /> 6. N ;M0 <br /> 7. cCC /1"� `W �°/�SSure SfiS cam► -� Z N m <br /> P � : <br /> l_y : € m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my dj c : p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a I, ': C <br /> all information contained in this application(including any accompanying schedule)and 1 further declare that I recognize m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to is- ( 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 m <br /> authorized person to have Ipsess to thSAlpve described premises at any reasonable time for the purpose of inspection. m E <br /> m : <br /> CD : <br /> SIGN HERE <br /> (signature of o er uil o o (date) . <br /> ZONING ADMINISTRATOR <br /> N N V 1 N N N N <br /> VI U O f71 fJ1 O O <br /> TOW HIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />