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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ' o o <br /> APPLICATION FOR LAND USE PERMITS 3 T <br /> r <br /> N O <br /> N <br /> C <br /> OWNERM a <br /> �`�'2 TELEPHONE <br /> HOME ADDRESS 3 f A/W J� fJ ��i <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER ^ q S--7 ROAD NAME . /�h l <br /> LEGAL DESCRIPTION (see tax receipt) <br /> L 17 X6)4 1 J f 3a- yu / J <br /> O <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION PRIVY ❑ 0 <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING 11CAMPING UNIT ❑ SUBDIVISION 11n' <br /> J ,,^ ) z— <br /> STRUCTURE/ADDITION USE: Fd�t�/"l /a �(3a, rna�/.�7i �/ <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) y <br /> BUILDING CONTRACTOR: T m' <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8Y:X 11 SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. n 3 <br /> O <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O d <br /> n O <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. T n ao Z <br /> �a <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m <br /> NORTH(N). <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 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. I o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO Q <br /> BUILDINGS,ROADS, LAKE, LOT LINES. I Q ` <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N -4V <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS ? G <br /> o <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN `~. o <br /> NEEDED. T <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o © 1 <br /> CONDITIONS OF PERMIT: (] <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT 1 <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 rl <br /> PERMITTED. V lVJ <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. / <br /> 5. <br /> m M. d d o M off. f m <br /> 6. m < 3am0n (D � <br /> "o CD C m o 5 �+ <br /> 7. Z n m o 1 <br /> O Tom ' m <br /> - N : A <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my pp � c <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of j m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize �UCL <br /> 0 <br /> CD <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- I <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 <br /> authorized person to have agcqs440 the above described premises at any reasonable time for the purpose of inspection. m <br /> Q / CD a <br /> m <br /> SIGN HERE,, l ( 74 / <br /> (signaturer f o er building contract /y (date) <br /> ZONING ADMINISTRATOR <br /> TO NSHIP PERMITS MAY BE REQUIRED �a70 y <br />