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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 <br /> r <br /> y O <br /> N <br /> C <br /> _ 9-66 sz ye <br /> OWNER S C 0 t— A H CG TELEPHONE a--p:j) Z&,---TS�P v <br /> CD O <br /> MAILINGADDRESS hyo ' M`&0d jk./ Lf}yL �(„/ /�p�01�srtl?T 1 0 <br /> PROPERTY ADDRESSL) <br /> 1 <br /> ,S- 7 T X/O X? /5 <br /> LEGAL DESCRIPTION(see tax receipt) tof' / C<3 m V//C/ Poo�5o' <br /> 5i <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION <br /> TYPE OF PERMIT(S): a <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ p <. <br /> STRUCTURE/ADDITIONUSE: <br /> (Home/Cabin;Commercial Business; Bedroom; Deck; etc.) <br /> 7 <br /> BUILDING CONTRACTOR: S C <br /> m _ <br /> CD <br /> v 1 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR In 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) n <br /> o Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE M O <br /> NORTH(N). 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m h 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. 0 <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO Q5 <br /> BUILDINGS,ROADS, LAKE,LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 0 SLl <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS I <br /> MUST BE SIGNED AND DATED BY THE OWNER. v j <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN S <br /> n <br /> NEEDED. v <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. ? I 1 <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT CI <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. QJ <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. m m iv n M CD .F m <br /> 3 am xa ° 7D <br /> 6. m <br /> iF CD N W N 7 0 <br /> Z y (D <br /> 7. 9 -n < . : m <br /> =V) <br /> I declare that this application (including any accompanying schedule)has been examined by me and to the best of my G>c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a N <br /> all information contained in this application(including any accompanying schedule)and 1 further declare that I recognize (DCD <br /> : M <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 ntB r IXin on this information I am <br /> providing in this application. I agree to permit county officials charged 't n g In antes or other o <br /> authorized person to ave access to the above described premises at an 1 i t u inspection. m-n o <br /> m mi <br /> (D <br /> SIGN HERET a E <br /> (signature of_gwner or building contractor) R 6' — 2W (dat J, <br /> ZONING ADMINISTRATOR (Yl t' 1 I C�( r <br /> 'tom (004069 r) <br /> b 7 vim` Cn O (n CT o0oO <br /> TOWNSHIP PERMITS MAY BE REQUIREC-ONING <br /> ffba ie- N-7�IIS PERMIT SHALL EXPIRE ONE YEAR FROM DATE OF ISSUANCE <br />