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102 Siren WI 54872 Office of Zoning Administrator V►� G) "1 0 <br /> Burnett County 7410 Co. Rd. K, No o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> Ca O O '\ <br /> 17 A ro l� � <br /> OWNER CjhTELEPHONE 7 X5-6 ^p <br /> -7609 Pe � 54 D�unj- 6OHOME ADDRESS <br /> CD <br /> EMERGENCY/FIRE NUMBER ROAD NAME Pe <br /> Daubuty WiS O <br /> � <br /> LEGAL DESCRIPTION (see tax receipt) loo i a P�� ��i+1 my <br /> #i <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ N ° <br /> c <br /> TYPE OF PERMIT(S): 1 n <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ (�j <br /> yl(11 <br /> � o <br /> STRUCTURE/ADDITION USE: r <br /> (H e/Cabin; Co ficial Business; Bedroom; Deck;etc.) Cn <br /> BUILDING CONTRACTOR: �A <br /> m <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR n 3 ` <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 uN <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) n a <br /> M Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. rrn o I�� <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE c 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 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF o <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. <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. C:) <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. IN <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS _ W <br /> MUST BE SIGNED AND DATED BY THE OWNER. f <br /> � I <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN <br /> n ° <br /> NEEDED. <br /> z <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. ° (� <br /> CONDITIONS OF PERMIT: I <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. 1 <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. J <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 /> �L , � � � � <br /> r- > 0 > 0 71 <br /> 0 ICD � * <br /> � a � <br /> A <br /> 7. <br /> ° T ` ; m <br /> 10 <br /> I declare that this application (includinh any accbilnpanying schedule) has been examined by me and to the best of my Gcc <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of p ' m <br /> N: CD <br /> all information contained in this application(including any accompanying schedule)and I further declare that 1 recognize l m p <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- f 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 <br /> providing in this application. I agree to permit county officials charged with d ini erin coun or otherCD <br /> authorized person tio have access to the above described premises t any e o I e t I o 1 i ection. m . <br /> m <br /> SIGN HERE <br /> ign re of w r or building contractor) JUf' <br /> f 1 _ 2uuvate) <br /> ZONING ADMINISTRATOR O <br /> BURNETT COUNTY <br /> TOWNSHIP PERMITS MAY BE REQUIRED ZONING lJ <br />