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CM& <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator M o 0 <br /> APPLICATION FOR LAND USE PERMITS . <br /> N � <br /> N <br /> C <br /> a <br /> OWNER TELEPHONE p <br /> f <br /> HOME ADDRESS m <br /> O <br /> EMERGENCY/FIRE NUMBER ROAD NAME tk �(� c1 <br /> I P <br /> LEGAL DESCRIPTION (see tax receipt) 3S - 39 Ae Al w s c�: 0 <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ C/ 0 <br /> TYPE OF PERMIT(S): <br /> n <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION /y /O <br /> STRUCTURE/ADDITION USE: V 10 ' <br /> /U (Home/Cabin; ommercial Business; Bedroom C <br /> eck;etc.) <br /> BUILDING CONTRACTOR: <br /> � � S <br /> 1 <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'/n X 11 SHEET OF PAPER. ANY INCOMPLETE OR ,n 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) n n <br /> T <br /> ?1 O Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE N o <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO rn ` -a <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. <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 2. <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> o � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN <br /> NEEDED. <br /> Z V <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. ° 1 <br /> CONDITIONS OF PERMIT: W <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. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. i <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5 CV Or DM CL :% m �. <br /> 0 al = C01 C m <br /> 3 nCDEj. <br /> 6. N N N 0 (O <br /> Z O <br /> 7. O T� m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of myar <br /> 2 A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize p <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 0 : <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 /> m : <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. - <br /> CDm <br /> SIGN HERE <br /> (signature of ner or building contractor) (date) �} <br /> ZONING ADMINISTRATOR 1 <br /> c <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />