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6 )I* <br /> Burnett Craunty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> N � <br /> C <br /> OWNER �AOH / ��v FEZ TELEPHONE �/ �; , 7 5- p <br /> J� / O <br /> HOME ADDRESS C)2SS /�R SO n/ LK Z) <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER 2ra2 2 ROAD NAMEcn <br /> H/ �G n✓E �D_ <br /> LEGAL DESCRIPTION(see tax receipt) _ �/ F 0 <br /> 7a�N v, <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ OF, cc <br /> TYPE OF PERMIT(S): !Jura Cr <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION l❑ S. <br /> N. <br /> STRUCTURE/ADDITION USE: �AJ2Ri F � n o <br /> (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) U <br /> BUILDING CONTRACTOR: <br /> U <br /> A PLOT PLAN MUST IJE PROVIDED ON AT LEAST AN 6'/:X 11 SHEET OF PAPER. ANY INCOMPLETE OR In 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. � N <br /> c <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) <br /> -M 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 m c <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m ^ -1 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF Clo <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. <br /> S. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS 0, <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN a E <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. 4J <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. ` <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. W <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 w <br /> SETBACK AREA. C <br /> 5. <br /> This structure to be used as private residentialCD v d d o L m <br /> s. garage/storage only. Not to be used for human e n W RL e z <br /> CD C N !A O <br /> N O O IO <br /> habitation. c :: i =M <br /> 7. _y. i : A <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my G3 c <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of �y o is <br /> m m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize �: G <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m <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 J <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> CD <br /> SIGN HERE <br /> (signature of own or uild g contractor) / (date) <br /> ZONING ADMINISTRATOR D' / 4 <br /> " 40 6% <br /> N tN11O0N OO <br /> 0 0 0 0 0 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />