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' -17 <br /> Burnett COunty 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Ad strator m o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> m o <br /> N <br /> / C <br /> OWNER ,!Q e� TELEPHONE <br /> HOME ADDRESS <br /> n cr l a/ o H� 1 <br /> ! , I t+ r <br /> 0 <br /> EMERGENCY/FIRE NUMBER " �� ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) <br /> ❑ _� 0'0 ' (C <br /> DO <br /> RY STRUCTURE 0 <br /> ADDITION ❑ PRIVY ❑ � o <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ o- <br /> n <br /> S. <br /> m <br /> STRUCTURE/ADDITION USE: h` �i �dh l✓if11 4y� f/ CtGh �Cl�44+P S <br /> // (Home/Cabin; Commercial Business; Bedroom; Deck; etc.) Cl) <br /> BUILDING CONTRACTOR: Er <br /> Lech r <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 =- <br /> ;U N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O n <br /> T Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. n m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m ( <br /> NORTH(N). C n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m a <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO t <br /> BUILDINGS,ROADS, LAKE, LOT LINES. ' <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. 'QW <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. coo <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN 0 <br /> NEEDED. o <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT (' <br /> ISSUANCE. W <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. J <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. <br /> e W C y : o 3 <br /> 7. zi yfDi �� '� <br /> O <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my p <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize CD m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- 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 m <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. T <br /> m : <br /> SIGN HERE gZ <br /> (signat r owner or ildl ntractor) (date) <br /> ZONING ADMINISTRATOR r��Oon0000.f "fn"fo"M rj "M- <br /> CA <br /> pONpOO <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />