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ICI <br /> Burn@tt'County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Adrninis rator" - o 0 <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N O0 <br /> N <br /> OWNERZN N I S W \ i (' l S 1 TELEPHONE (Q s(-y_5 -(0 7 9 3 o Q f <br /> / <br /> O <br /> HOMEADDRESS (Qs,7j ATWEnlA VAI, Tn/t/i=2 &rott9- SSIY11 <br /> EMERGENCY/FIRE NUMBER4 o � <br /> ROAD NAME V V w Nap- L R /�kd. I <br /> LEGAL DESCRIPTION(see tax receipt)Lo-T 15 /IJ cys�n/M�.J�- Lo-rS 2 AA/d.3 SIF-cTlcnl 1 Cf) - <br /> o- <br /> m <br /> DWELLING/BUILDING M GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY 41 R 15 (J rn s' <br /> TYPE OF PERMIT(S): Q !)t\ <br /> FILLING/GRADING CAMPIN UNIT ❑ SUBDIVISION ❑ n _/ -� <br /> N C <br /> STRUCTURE/ADDITION USE: 0 m I- A b 1 1'r <br /> (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) m <br /> BUILDING CONTRACTOR: L L l <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81AX 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 (^ <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T " I <br /> ;a y _� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o <br /> nZ <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). y 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m v <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. ((� c S <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO I " ) <br /> BUILDINGS, ROADS,LAKE, LOT LINES. ' <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. C� N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR, ETC.,THE PLANS C <br /> MUST BE SIGNED AND DATED BY THE OWNER. 'o 0 <br /> kj� <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN �» S ` <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS YSF <br /> ISSUANCE. ) <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG a 1 -� <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIF <br /> PERMITTED. tttlll��Y�Y <br /> 4. NO STRUCTURES, INCLUDING I�ETA�NING WALLS ET ,ALLOWED WITHIN THUIR TIER <br /> �n 11''�� �, // a <br /> 5 SETBACK AREA. (A k ��r lJ�l" <br /> �( 1 (�1q' <br /> n DNOy DANEWCOU 'o mDa <br /> 36. f N� CD C jat1�INZ <br /> m <br /> COD <br /> o <br /> I declare that this application (including any Mcompanying schedule) has been examined by me and to the best of my 9 G) c C <br /> • <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of J. Q ^ A <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize ' ° m <br /> that this information I am providing will be relied upon b the County of Burnett Wisconsin in determining whether to is <br /> \\ <br /> P 9 P Y tY 9 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 am d: ° <br /> providing in this plication. I agree to permitpQunty officials charged with administering county ordinances or other <br /> CD <br /> authorized p rson t have access to the above 4eerlbecl preinises at any reasonable time for the purpose of inspection. n <br /> m <br /> SIGN HERE <br /> (si nat re of ow r building contractor) (date) <br /> ZONING ADMINISTRATOR C N <br /> TOWNSHIP PERMITS MAY BE REQUIRED � �p v <br />