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Burnett C6unty 7410 Co. Rd. K, No. 102, Siren,WI 54872Office of <br /> APPLICATION FOR LAND USE PERMITS Hing Administrator CD 0 0 <br /> r <br /> N <br /> C <br /> OWNERc <br /> IWl I: r Y TELEPHONE <br /> d ` O <br /> HOME ADDRESS O <br /> i � <br /> EMERGENCY/FIRE NUMBER �\C� ROAD NAME ���L..:GCla o <br /> LEGAL DESCRIPTION(see tax receipt) <br /> W — <br /> L3N CAI" U// P/d7-//6 c, <br /> �( <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE,CJ ADDITION ❑ PRIVY ❑ o <br /> TYPE OF PERMIT(S): � <br /> c <br /> FILLING/GRADING 0 CAMPING UNIT ❑ SUBDIVISION ❑ c <br /> STRUCTURE/ADDITION USE: Czalizatis„_f <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.)` --T <br /> y C <br /> BUILDING CONTRACTOR: �a � <br /> Er !- <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY PLETCD <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 3 <br /> 0 N <br /> DIRECTIONS FOR PLOT PLAN DRAWING, (AERIAL OR TOP VIEW) , <br /> T Q O 1 <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n CL <br /> o V Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m `? <br /> NORTH(N). O <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m <br /> CENTERLINE OF ROAD,(C)BUILDING(S)LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS.INARY HIGH WATER MARK(OHWM)OF I c <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. O o <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o O - <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN NEEDED. <br /> Cr <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z Q <br /> CONDITIONS OF PERMIT: O <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> Q1 <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. 1 <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> 6. A170r' 17017 <br /> 3 C=L 1 m <br /> 'O M C N y 0 <br /> 7. Z y N O O f0 <br /> o <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the ca70 <br /> best of my , m <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracyof ' m ° ` ` ': C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize rn m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- <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 0 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access 10 the above described premises at any reasonable time for m <br /> the purpose of inspection. <br /> CD <br /> m <br /> SIGN HERE <br /> (sije#ruildlng actor) (date) QQZONING ADMINISTRATOR CAN Nf7iNN NNTOERMITS MAY BE REQUIRED 0 N O N pt O O <br /> 0000000 <br /> 0000000 <br />