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5FrWd 1iqtaC 0� n&�t dl-c bctt <br /> GI'e,C1{G. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -a O Z <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> r � 1 <br /> OWNERrrX C Np m r,-s /MG TELEPHONE ZO 37 Q 1_5'y0 <br /> m � <br /> HOME ADDRES035 77 w; D v9'0.5CR wr SVGg. <br /> f <br /> 0 <br /> EMERGENCY/FIRE NUMBER .73-77 ROAD NAMES o <br /> LEGAL DESCRIPTION (see tax receipt) C ..�p, / fO rN <br /> (S Cnm <br /> a <br /> DWELLING/B I ING GA GE/ACCESSORYSAD ITION ❑ PRIVY rn o <br /> TYPE OF PERMIT(S): C <br /> FILLING/GRADI AMPING UNIT ❑ SUBDI n <br /> STRUCTURE/ADDITION USE: o' <br /> ome/Cabin; mmercial Business; Bedroom; Deck; etc.) <br /> m <br /> BUILDING CONTRACTOR: S^f<< '- (> <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8Y:X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n 3 <br /> M w <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p m O <br /> n a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. -n b <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m S <br /> NORTH(N). C n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m w 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. ' o <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. G Q <br /> S. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. NR ` <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. o t <br /> J v 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN 1. F5, o, `Y <br /> NEEDED. r �� <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z T' <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT N r n <br /> ISSUANCE. � <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONOISIN — I <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPEC I <br /> PERMITTED. J�� ��I�i <br /> 4. NO STRUCTURES, INCLUDING RET INING WALLS, ETC.,ALLOWED WIT�H}JI/N� REQUIREDWATQE/Ry <br /> SETBACK ARE . <br /> 5. OnSI'L A"/1', f1-01 `S PS !V €•d$ � PP) <br /> v` I <br /> p' m � m °r' � ° n f m <br /> 6. BURNS 7.7. CO m S a m D a m ;U <br /> 7. ZONINGZ : y M ° N ' 3 <br /> o : 21, m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my JD <br /> 0 c <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m 0 m i <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- i <br /> G7 <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. IAgree to permit county officials charged with administering county ordinances or other o <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> p m <br /> SIGN HERE �.j 5S L.1-IT 711�/Z)� `^ <br /> (signature of owner or building contractor) (date) .21 <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> G <br />