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j-21 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator v O Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r <br /> 15. <br /> N � <br /> N <br /> OWNER TELEPHONE JSid(P� _ ���C/ <br /> CL V <br /> HOME ADDRESS q57— L Cjez �r,� A �1 l erg/ �� ,S y00/ V 0 <br /> r M <br /> EMERGENCY/FIRE NUMBER 7 a ROAD NAME 0 <br /> S©7 Tyo 7S 4)n 2.78 CD A a� <br /> LEGAL DESCRIPTION(see tax receipt) <br /> TYPE OF PERMIT(S): <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ y o r f <br /> � � <br /> FILLING/GRRADING/❑ CAMPING UNIT ❑ SUBDIVISION ❑ a <br /> STRUCTURE/ADDITION USE: r CqV( 0'L <br /> (Home/ ¢ <br /> C/a ommal Business; Bedroom;Deck;etc.) <br /> BUILDING CONTRACTOR: CrJQ <br /> (01.7 2. <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'%X 11 SHEET OF PAPER. ANY INCOMPLETE O m <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. c �� m 3 <br /> l 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) ---�— 0 �� C <br /> n 0. <br /> 1. 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 IF <br /> NORTH(N). C n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 03 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF 0 <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 0 <br /> BUILDINGS, ROADS,LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. CDPN <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. c I <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONEWHEN 0 <br /> NEEDED. <br /> a B. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z L� <br /> CONDITIONS OF PERMIT: <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. a <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 /> XMnrv� vv <br /> a n <br /> m <br /> 6. I'o3� v , 'der — m <br /> 7. Za v 0� 3 <br /> o .-G <br /> 1y: m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of myC ; p <br /> knowledge and belief it is true,correct and complete. 1 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 0'mto is- <br /> m <br /> whether <br /> Is- <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin In determining v <br /> sue a permit. I further accept all liability which may be a result of the County of Burnett relying on this information I Is i <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 /> CD : <br /> SIGN HERE <br /> (si a re of owner o b ildi contractor) (date) <br /> ZONING ADMINISTRATOR l 'tom aL E E <br /> NM M N Nfcrl 01 <br /> Vn N O U(T OO <br /> TOWNSHIP PERMITS MAY BE REQUIRED0 0 0 0 0 0 0 <br />