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J C) Y i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator a ci <br /> APPLICATION FOR LAND USE PERMITS 3. 4 <br /> bir <br /> ' y O <br /> N <br /> c <br /> OWNER e�74 /U Y /_I�J C��/� TELEPHONE L)L��� o (1 <br /> t m 1 <br /> HOME ADDRESS O�O � � w C7 R�Q�') � <br /> EMERGENCY/FIRE NUMBER 23 7 O ROAD NAME <br /> LEGAL DESCRIPTION(see tax receipt) "�1 13 e5 �� c <br /> C) <br /> TYPE OF PERMIT(S): DWELLING/BUILDING RC ACCESSORY STRUCTURE ADDITION v <br /> Q: <br /> 5. <br /> N <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION <br /> 01 D <br /> STRUCTURE/ADDITION USE: <br /> U Gar� <br /> (Home/Cabin; Comrf4rcial Business;Bedroom;Deck;etc.) <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR n <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> x c <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O <br /> ?� Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m [''o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <br /> n <br /> in 0 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO M 3 <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> STREAM OR RIVER. o <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. <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 <br /> o � <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE <br /> Cr. <br /> ISSUED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z I <br /> CONDITIONS OF PERMIT: Pn , <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT � <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. �Y <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 /> 6. 1 � 3 Crn N c <br /> � ; <br /> 7. ? m OQ ' ? <br /> O : <br /> .N; <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my i di Cr C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of m <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize ' m O <br /> 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 m <br /> providing in this application. 1 agree to permit county officials charged with administering county ordinances or other m E <br /> authorized person to have access to the above describe remises at any reasonable time for the purpose of inspection. n <br /> CD : <br /> r a : <br /> SIGN HERE / oZ 9 7 <br /> owner orb ding contractor) (date) <br /> ZONING ADMINISTRATOR v, <br /> HHHH�u� <br /> N N V1NNfJ1 fT <br /> V7 Vt O Vt fTOO <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />