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cf yL Ccn'�t�O <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -Ill o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. 4 <br /> r <br /> a ° <br /> D / 7 4VTda " � <br /> OWNER 44) C X 2 „ /U TELEPHONE — S <br /> HOME ADDRESS Spy 7dZ / Ten S -,�5�fj 0y jt -e aq to f c4'dc r 12'� - h©J v <br /> ,� 1 <br /> EMERGENCY/FIRE NUMBER ROAD ROAD NAME W <br /> LEGAL DESCRIPTION(see tax receipt) 1 CS'H �� 18 9 (� CDQ <br /> J 7 <br /> �( m <br /> TYPE OF PERMIT(S): DWELLINGIBUILDINGLGARAGE/ACCESSORY STRUCTURE r' ADDITION Q <br /> n <br /> o' <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION � <br /> y <br /> STRUCTURE/ADDITION USE: Ld �i h. 7 kA4 C< _ <br /> (Home/Cabin; Commercial B iness; Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INS CQMPLETE OR _ <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. I�,/_1 {— , —Q� © , 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) S <br /> I U�SVI�N/Lt SL'/fJL}(/� r <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. 0 m s Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m S 6e) <br /> NORTH(N). y c <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m �Iv <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, <br /> STREAM OR RIVER. (51 <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- (� <br /> INGS,ROADS, LAKE, LOT LINES. 9r!,,j <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 64 <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS <br /> MUST BE SIGNED AND DATED BY THE OWNER. n' o <br /> v � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE Cr <br /> ISSUED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z 1 <br /> CONDITIONS OF PERMIT: P <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT l <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. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN 75 FEET OF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> n <br /> a <br /> 6. a CH w o� 3 <br /> 7. <br /> Cr i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my a5c p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of C (? S <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m a , m <br /> that this Information I am providing will be relied upon b the County of Burnett Wisconsin in determining whether to is- r^ y ; O <br /> P 9 P Y IY 9 <br /> Is- <br /> sue a permit. I further accept all liability which may be a result of the t <br /> ri I Information I am m <br /> providing in this application. I agree to permit county officials cha i ardtgances or other E m E S <br /> authorized person to have access to the above described premises of inspection. m <br /> o : <br /> e <br /> SIGN HERE <br /> sig tura of r r building contractor) ate) . <br /> ZONING ADMINISTRATOR guRNETT COUNTY <br /> ZONING o, <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 <br />