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6" �0 , <br /> Burnett County 7410 Co. Rd. K, No. 102,Siren,WI 54872 Office of Zoning Administrator -0 o 0 <br /> APPLICATION FOR LAND USE PERMITS I <br /> N O <br /> w <br /> /� c <br /> OWNER D4Ulb TELEPHONE 012-2V --,5-720 0 <br /> 7� <br /> HOME ADDRESS 70 `e, 05&17-Rl' RlJ f ��na �}'�/v � 0 <br /> EMERGENCY/FIRE NUMBER t&A/ 4 MA1. �' ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) 175' O 370Q $'0O l m <br /> w <br /> TYPE OF PERMIT(S):DWELLING/BUILDING—, —GARAGE/ACCESSORY STRUCTURE X DDITION Cr <br /> CL <br /> N. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin;Commercial Business;Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O <br /> � c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m 'q <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE c n <br /> NORTH(N). y3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m v <br /> CENTERLINE OF ROAD, (C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, U�Z <br /> STREAM OR RIVER. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- a <br /> INGS,ROADS, LAKE, LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER, BUILDER,CONTRACTOR, ETC.,THE PLANS l� <br /> MUST BE SIGNED AND DATED BY THE OWNER. m o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE a <br /> ISSUED. <br /> I <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c (� <br /> CONDITIONS OF PERMIT: W <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> d <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 /> p -0nr6. o�om <br /> QwQ �. d5 Lk <br /> M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c i '• i O <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of o.` S <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m B m <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- y 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 ; m ; <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have cess to the abo Bribed prem ses at any reasonable time for the purpose of inspection. T <br /> w : <br /> ,o w <br /> SIGN HERE <br /> (signature of owner or ng c c (date) <br /> ZONING ADMINISTRATOR �d <br /> N N N N VI <br /> N N Cn UI O <br /> TOWN IP PERMITS MAY BE REQUIREDC)0 <br /> Ube _5°rrr l0--iy`7 <br />