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z <br /> Burnett County 7410 County Road K, No. 102, Siren, WI 54872 Office of Zoning Administrator a ° <br /> APPLICATION FOR LAND USE PERMITS y <br /> OWNER �.CIV'� G "(I rl 1�.✓Jit p//� �Y��, TELEPHONE- , 44 -11 <br /> V 1 4'? t' 1 &j7 � O <br /> ro O <br /> MAILING ADDRESS <br /> H440 <br /> „)W) Cq �j W I � CI V' � I��� CTI <br /> PROPERTY ADDRESS �a �kj <br /> LEGAL DESCRIPTION '' sir <br /> TYPE OF PERMIT(S): SINGLE-FAMILY DWELLING ❑ ADDITION DECK ❑ GARAGE/ACCESSORY STRUCTURE ❑ w <br /> BUNKHOUSE ❑ 59.692(1V)GAZEBO ❑ STAIRS ❑ FILLING/GRADING ❑ CAMPING UNIT❑ a <br /> COMMERCIAL BUILDING III <br /> COMM F7I RCIAL ADDITION ❑ COMMERCIAL ACCESSORY STRUCTURE ❑ c <br /> STRUCTURE/ADDITION USE: <br /> 0 <br /> (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) _ <br /> BUILDING CONTRACTOR: H-Q l` WV t'W4L'1 <br /> n <br /> r � <br /> O <br /> A PLOT PLAN MUST BE PROVIDED ON AN 8 rh X11 SHEET OF PAPER. ANY INCOMPLETE OR ILLEGIBLE PLOT PLANS o_ <br /> WILL BE RETURNED. .rl <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (ARIAL OR TOP VIEW) m 6 <br /> O <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/STRUCTURES (EB) AND ALL NEW m w <br /> BUILDINGS/STRUCTURES (NB), INCLUDING DECKS, PORCHES AND OTHER STRUCTURES, a <br /> AND INDICATE NORTH (N). NqjZ <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A) BUILDING(S)TO ALL LOT LINES, (B) BUILDING(S) 0 0 <br /> TO CENTERLINE OF ROAD, (C) BUILDING MEASUREMENT(S)TO THE ORDINARY HIGH WATER MARK <br /> (OHWM) OF LAKE, STREAM OR RIVER AND WETLAND AREAS, AND (D) LOT DIMENSIONS. p <br /> 4. SHOW THE LOCATION OF THE WELL(W), SEPTIC TANK (ST) AND DRAINFIELD (DF), AND ALL DISTANCES UP( <br /> TO BUILDINGS, ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER, CONTRACTOR, ETC., THE <br /> PLANS MUST BE SIGNED AND DATED BY THE OWNER. i y <br /> 9J 1 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MY BE DONE WHEN <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT. m Z <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. 1 A <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC., ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. z <br /> 5. ACCESSORY STRUCTURE/GARAGE PERMITS ALLOW FOR PRIVATE RESIDENTIAL GARAGE/STORAGE ONLY. <br /> NOT TO BE USED FOR HUMAN HABITATION. <br /> 6. <br /> 7. a o 0 o n c p 7 <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all a m d d = a .j <br /> Information Information 1 contained <br /> providing be relied ncluding any accompanying schedule)and I further declare that I recognize that this a > > a <br /> p g upon by the County of Burnett Wisconsin in determining whether to Issue a permit. I .� �. c w > <br /> further accept all liability that may be a result of the County of Burnett relying on this Information I am providing In thisv H w.n '_^ „`^, 7 <br /> access tlo the above-desee to cermit ribed premises at any reasonable cials charged htlme for administrating <br /> of Inspection. <br /> lor other authorized person to have o o o <br /> W b0 a O W W N W <br /> 61 Y1 ZC ; � d , � oo � � a <br /> c <br /> OWNER'S SIGNATURE �” = 1° 'L'aam �, <br /> ZONING ADMINISTRATOR <br /> Z; M <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> THIS PERMIT SHALL EXPIRE ONE YEAR FROM DATE OF IS COUNTY N N o N U o <br /> ZONING <br />