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Burnett 04unty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator ' ° o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> a 0 <br /> N <br /> I, f t 7✓''' �i C C� <br /> OWNER J Ilan)O'LT� J��rkP I t�hPr TELEPHONE l&^3I (i/�/ <br /> HOME ADDRESS "/(O� L-Fl �'Ti� 'VY14w' �� ' /fl Q r 0 <br /> EMERGENCY/FIRE NUMBER d 67 3 ROAD NAME LV,`^ 14�l / <br /> LEGAL DESCRIPTION(see tax receipt) `� Dn 3 3 �V/J � � A-r7IJ <br /> ��l— 1,L <br /> TYPE OF PERMIT(S):DWELLING/BUILDING—GARAGE/ACCESSORY STRUCTURE ADDITION 1 ' <br /> 0 <br /> Q <br /> 5 <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION cw)up <br /> Sca <br /> ( I <br /> 0 V� <br /> )qa <br /> STRUCTURE/ADDITION USE: 1 /i'i L - <br /> l�P.� / Ze 4 <br /> (Home/Cabin;Commercial Business; Bedroom;Deck;etc.) <br /> T <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR G 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. _ <br /> A (� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O w <br /> In n <br /> :2 � p <br /> 2 <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. � � <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m n <br /> NORTH(N). y ° <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, <br /> STREAM OR RIVER. f , o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- V 1 <br /> INGS,ROADS, LAKE, LOT LINES. 1 <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. <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE �o <br /> ISSUED. HCl a <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: 1Tti_I <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. Q <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. LU I <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 q`FHWM OF LAKES, �I„! <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> 6. I rll Ij/ � 3n '�CQM <br /> Cw '" 5 3 <br /> 7. I / ,I �LJill zi !ft 1p � <br /> p <br /> I declare that this application (including any accompanying schedule) hac n eza a to the e't of my g p <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible ' el and` uracy of �; <br /> all information contained in this application(including any accompanying schef er declare th cognize � <br /> that this information I am providing will be relied upon by the County of Burnett Wisco i n whether to is- <br /> Bum <br /> s- (� O <br /> sue a permit. I further accept all liability which may be a result of the County of Burn f�enn tt a I formation I am W'• '• <br /> providing in this application. I agree to permit county officials arged with administering county, ordinances or other ; `m <br /> authorized person t)-Vave access to the above described pregribes Ot any reasonable time for the purpose of inspection. <br /> m E <br /> SIGN HERE �� C <br /> (signature/of owner or building 4ntracto ) (date) <br /> ZONING ADMINISTRATOR --� . . . . . . ' <br /> in 169 40 <br /> N N°1 NNN(T <br /> 1��t V7 (T0t71N 00 <br /> TOWNSHIP PERMITS MAY BE REQUIRED0 0 0 0 0 0 0 <br /> t 1 0000000 <br /> l�✓ <br />