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r I <br /> Burnett County 7410 Co. Rd.K, No.102, Siren,WI 54872 Office of Zoning Administrator v �. <br /> APPLICATION FOR LAND USE PERMITS <br /> OWN EF4/O{4 Sy,,y� 'I1} P TELEPHONE Imo,/ `,/ d <br /> al <br /> i O <br /> HOME ADDRESS 8139 PehnsHLJGvtito elrE� $ �oaN�, � (n1i� SS'Y3c4 <br /> r m <br /> 0 <br /> EMERGENCY/FIRE NUMBER a "1 b� ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) 1=�v I ) �, —�-0/J R!S V ca <br /> QS <br /> Cn o <br /> TYPE OF PERMIT(S): DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE ADDITION a , n <br /> N <br /> VJ <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> ca <br /> STRUCTURE/ADDITION USE: T,T� @'� � Alhr,�, �� � 6t <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> m 1 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> ;0 N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O <br /> O Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 'o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m 0 <br /> NORTH(N). y o <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m 1 Z <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, <br /> STREAM OR RIVER. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS,ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. i <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS 2. <br /> MUST BE SIGNED AND DATED BY THE OWNER. C <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> ISSUED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: --0 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT IU yr�n <br /> ISSUANCE. �D <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. 3 <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES,INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN 75 FEET OF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. I' _ QQ <br /> M '00r V O 10 <br /> m <br /> 6. See tri ailCe `�� m is <br /> baa fn <br /> F w o : o m <br /> 7. e ' a <br /> —ca <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my E c E E A <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of a ` C <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 by the County of Burnett Wisconsin in determining whether to is- m 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 m <br /> providing In this application. I agree to permit county officials charged with administering county ordinances or other n <br /> authorized person t ave access to the jbpve described premises at any reasonable time for the purpose of inspection. m <br /> m : <br /> CD : <br /> SIGN HERE <br /> (signatifre of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR J Ifn Ril� 91,9" <br /> �^ <br /> N <br /> tr NO Pfnn 00 <br /> O 0 0 0 0 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0000000 <br />