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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of <br /> APPLICATION FOR LAND USE PERMITS Hing Administrator o 0 <br /> N <br /> JIJ <br /> N <br /> // C <br /> OWNER <br /> 80.4 FL,<0.�Sn <br /> .Spirt IJ TELEPHONEl�s <br /> HOME ADDRESS / ``'' /( jjr m `5�1 <br /> !L'Syy /Y04.Jex Let <br /> K4 Qe-f �a.r ura Lel: y�3P� O�U` <br /> EMERGENCY/FIRE NUMBER �ga �/ ROAD NAME �,l/ �x� <br /> Lot>�SI C( <br /> LEGAL DESCRIPTION(see tax receipt) Cn <br /> l <br /> m <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ .� o <br /> TYPE OF PERMIT(S): m � <br /> c <br /> FILLING/GRADING 0 CAMPING UNIT ❑ SUBDIVISION ❑ a <br /> STRUCTURE/ADDITION USE: C' 0.M4 4 e ak1j V H <br /> o' <br /> (Home/Cabin, Commercial Business; Bedroom; Deck;etc.) Cn ' <br /> BUILDING CONTRACTOR: <br /> fir <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'%X 11 SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. ' _ -n 3 <br /> O <br /> DIRECTIONS FOPLOT PLAN DRAWING, (AERIAL OR TOP VIEW) ;VR <br /> c o <br /> 0 a � <br /> f. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). C <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TOm \ 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF v <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. O z <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 /> 6. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <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. 91 <br /> m c <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN <br /> NEEDED. q <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <br /> CONZDITIONS OF PERMIT: o <br /> I. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. Q <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. /411 <br /> �j <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY �L <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. C <br /> 5. <br /> 6. <br /> m1� C� am �_ � <br /> 7. H y o S <br /> OZ N 4 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 4 m <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 m E <br /> CD <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- G) m <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 <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. to <br /> m : <br /> m <br /> c CD ; <br /> SIGN HERE � <br /> (sl atu of o r o building contractor) 40 /vt' <br /> ZONING ADMINISTRATOR <br /> kwwwvw 49 <br /> ut N O N�OO <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 <br />