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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872gym <br /> APPLICATION FOR LAND USE PERiceMITS of ning Administrator o <br /> _3 <br /> N <br /> OWNER ( TELEPHONE ��� 3 Z-7Q7 �� o- o <br /> HOME ADDRESS //1/03 / o <br /> f <br /> EMERGENCY/FIRE NUMBER / L�O l L� / /(lam pr =° <br /> ROAD NAME TQC,/ /�/at `7' a <br /> LEGAL DESCRIPTION (see tax receipt) <br /> LlfD <br /> DWELLING/BUILDING <br /> TYPE OF PERMIT(S): GARAGE/ACCESSORY STRUCTURE ADDITION <br /> PRIVY ❑ <br /> FILLING/GRADING g ° ®.,. <br /> ❑ CAMPING UNIT ❑ SUBDIVISION ❑ n <br /> STRUCTURE/ADDITION USE: L74 <br /> � fin' a� � o <br /> me Cab ; ,ommerclal Business, Bedroom; Deck;etc.) <br /> BUILDING CONTRACTOR: <br /> m <br /> PLOT PLAN MUST BE PROVIDED LEAST AN 8'/:X 11 <br /> I SHEET OF PAPER.PLOT PLANS WILL BE RETURNED. <br /> . ANY INCOMPLETE OR (DNED. 3 <br /> -n <br /> DIRECTIONS FOR PLOT PLAN DRAWING• (AERIAL OR TOP VIEW) O <br /> y <br /> O m <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n o Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE A <br /> NORTH(N). m <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 3 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT WETLAND AREAS. <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTICOTANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO o <br /> BUILDINGS, ROADS,LAKE, LOT LINES. ` <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. Q , N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS 6 <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 V\ a o <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. � <br /> CONDITIONS OF PERMIT: 0 1 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT J <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. /_ ry <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER Ip <br /> SETBACK AREA. <br /> 5. m CD -0 g > o n o � <br /> M. <br /> 7. N C N N ° 3 <br /> Z : y m ° f° —1 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ° A <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of o C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize <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 <br /> providing g <br /> P g in this application. 1 agree to permit county officials charged with administering county ordinances or other <br /> authorized pers to have access tot o described premises at any reasonable time for the purpose of inspection. (D <br /> m : <br /> C <br /> SIGN HERE m <br /> (sig to o r or building contractor) - <br /> / (date) <br /> ZONING ADMINISTRATOR t� <br /> TOW HIP PERMITS MAY BE REQUIRED <br />