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Burnett.,county 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 c) Z <br /> APPLICATION FOR LAND USE PERMITS 3. Qj <br /> r <br /> N O <br /> N <br /> _ C <br /> OWNER1je-5- TELEPHONE L n <br /> O <br /> m <br /> HOME ADDRESSRIM <br /> EMERGENCY/FIRE NUMBER ROAD NAME <br /> I <br /> LEGAL DESCRIPTION(see tax receipt) LOTl f n U o m <br /> 1 0 <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION PRIVY ❑ Q c <br /> TYPE OF PERMIT(S): o <br /> FILLING/GRADING ❑ CAMPING UNI [] ,SUBDIVISION <br /> ❑ '` ® /' a <br /> STRUCTURE/ADDITION USE: ����M3 �QSNNt �( rte( Ot'A'r�!/� Cf) <br /> ( o abi Commercial Busine s; Bedroom; Deck;etc.) m <br /> BUILDING CONTRACTOR: <br /> e � <br /> C <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 o <br /> ?� Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n oOi jp <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m :? <br /> NORTH(N). CO) c <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF 30 Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. <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 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. (:1 0 1 <br /> v � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q <br /> NEEDED. —oma <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: 0 <br /> SO <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, <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> zv0rCD W .- vLvv <br /> 6. IP � 3amO2 <br /> � <br /> m C (Ni, N O O Z <br /> CMD =iJ <br /> 7. Z y �� ' � � <br /> O . <br /> _q : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my �j c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this information 1 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 access to the above described premises at any reasonable time for the purpose of inspection. -n <br /> m : <br /> m : <br /> SIGN HERE ! Q <br /> (sig re oferorb 'mgc t c /date) <br /> ZONING ADMINISTRATOR L . • • • . , fn <br /> cn eA 69 40 49 69� <br /> N NCn N N)0 (n <br /> OI On O (n 0100 <br /> TOWNSHI PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />