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&� cPy, <br /> Burnett County 7410 Co. Rd. K, No.102, Siren,WI 54872 Office of Zoning Administrator V o 0 <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> ` <br /> OWNERIl GTELEPHONE i p3 "315 Oq <br /> OSehn clYy. <br /> L"(✓L✓1 <br /> HOME ADDRESS 'a9 / 70+i S+- Lo+L[ 5t C r0 I X Fa 115 VAX f o <br /> EMERGENCY/FIRE NUMBER ked Lty <br /> ROAD NAME H ill 1 o P <br /> s E r! &-C sw % .5e4lo„34 7-39 At, R I� CJ y o <br /> LEGAL DESCRIPTION(see tax receipt) o <br /> n <br /> Q <br /> TYPE OF PERMIT(S):eWELLINGBUILDING _GARAGE/ACCESSORY STRUCTURE XADDITION n <br /> a IN <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION 0 <br /> m <br /> STRUCTURE/ADDITION USE: YYIOh'Il Late -3S ✓(S `Ir le[ � <br /> (Home/Cabin;Commercial Business; Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR Q` In 3 (9 ) <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. See P_azot.� 0 <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 F �u <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE C n <br /> NORTH(N). 3 v <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m <br /> ^ <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, V Z <br /> STREAM OR RIVER. <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. S 1 <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. 0 <br /> o _ <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE Cr ° bi <br /> ISSUED. n <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: (} � <br /> X/ I <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. <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. Xlu o�o � <br /> m <br /> 6. w o �6 <br /> Z : <br /> 7. o Vim € i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my g ' C <br /> knowledge and belief It is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of c , <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize �^ m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m ? t7 <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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other im <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> lei L21 / ki l /0 q H <br /> SIGN HERE ^� <br /> (sign c_o_f_owner <br /> �or building contractor) (date) I <br /> ZONING ADMINISTRAT <br /> �` �� • N N N N <br /> OOPIN <br /> f]i � N O <br /> O O O O O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 000 <br />