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" Cfn/0 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator 'a Q Z <br /> APPLICATION FOR LAND USE PERMITS _ <br /> r <br /> N 0 <br /> N <br /> / _ C <br /> OWNER D� `1 R00'1' L91,3iZ9 AXI TELEPHONE A11 n <br /> o <br /> HOME ADDRESS Zg 9°�•- ��Nle TEC AJ <br /> stc'. Lk)-T-- <br /> EMERGENCY/FIRE <br /> EMERGENCY/FIRE NUMBER "4C6 qS2 ROAD NAME Sp"12, 6Rrr✓n y .. <br /> LEGAL DESCRIPTION(see tax receipt) 7 '}' �� R (�. �� Z( W m <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE X ADDITION ❑ PRIVY ❑ rn <br /> TYPE OF PERMIT(S): a ' <br /> FILLING/GRADING F-1CAMPINGUNIT ❑ SUBDIVISION ❑ °' <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; CommercialBusiness; Bedroom; Deck;etc.) U) ' �1 <br /> BUILDING CONTRACTOR: sr <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8'h X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> M N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O n O C, <br /> In 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 <br /> 3. SHOW D M)ENSIONS 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 Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. P <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. t y, <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. m 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN ��° <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z i <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. W <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 /> `S�TBACK AREA. / /f A , <br /> 111 r� te/ A ,=U wo OHM <br /> 6. � 3 nM RLa- <br /> v mCy !" o � 3 <br /> 7. ? : N :tj� <br /> CO m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of ? C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize Q <br /> M <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- O <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 y' <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other to <br /> authorized person to hag access to the above describe4 premises at any reasonable time for the puposq of inspection. CP <br /> T E <br /> SIGN HERE 04 / <br /> (slg ature of owner or uil Ing contrac r (date) <br /> ZONING ADMINISTRATOR <br /> N Nfn NN <br /> ul V\ OU1N P0P0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 <br /> 000000 <br />