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Burnett rout-4 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator - o <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> ie O J�.J <br /> J�/�N� �PqYe2 / / N <br /> OWNER m TELEPHONE <br /> HOME ADDRESS a16 q a4 / ( " s <br /> EMERGENCY/FIRE NUMBERW�� _7'9g, f �6� ROAD NAME W /I ID � �+ e <br /> 64S rA <br /> LEGAL DESCRIPTION(see tax receipt)-4�r_ iC pyt <br /> r n <br /> DWELLING/BUILDING;9 GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ rn <br /> TYPE OF PERMIT(S): c <br /> FILLING/GRADING ❑ CAMPING UNIT ElSUBDIVISION ❑ a <br /> < f <br /> STRUCTURE/ADDITION USE:— D (f--, o' <br /> // (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) m <br /> I <br /> BUILDING CONTRACTOR: <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8Y:X 11 SHEET OF PAPER. ANY INC m <br /> PLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. BNS* 19 T <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O K44 O <br /> m n <br /> -n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OH <br /> WM)OF � " <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. V' 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. <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 PLANS N <br /> (� N <br /> MUST BE SIGNED AND DATED BY THE OWNER. o <br /> o 0 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHENCr o <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: P <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT r� <br /> ISSUANCE. V <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. � r <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY J <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN THE REQUIRED WATER c <br /> SETBACK AREA. bu <br /> 5. <br /> X V n O O <br /> m �. 3 � m m <br /> 6. m � D o. 1W 9; <br /> 9 N C N <br /> 7. Z fA j� � 1 <br /> O T A <br /> =m: m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my �j c p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of m C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m m M <br /> m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is. \ m : 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 administering county ordinances or other �Q m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. -n <br /> m : <br /> SIGN HEREpv\ <br /> (s nat re of owner b I i g contractor) (dat ) <br /> ZONING ADMINISTRATOR E 49 <br /> N N N N N (n 01 <br /> utOut V10 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />