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l <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> N O 90 <br /> L�i� LD � WIZ 612_g,9_o - <br /> OWNER A � TELEPHONE 115.,,ZS9 -3263 <br /> HOME ADDRESS 2SO4. HAYe-S CT. , BURNSVil_i..0 M1j, r-53u <br /> o <br /> 0 <br /> EMERGENCY/FIRE NUMBER29ROAD NAME <br /> a� <br /> 4-oic-i V"" Io P4-�5 <br /> LEGAL DESCRIPTION (see tax receipt) S 0I h40IR15 PU—..Gov, (.-Off I 1—40 —15 —OI—OC7 � � y <br /> N <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ElADDITION ® PRIVY El CO <br /> TYPE OF PERMIT(S): U <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ 5 , <br /> STRUCTURE/ADDITION USE: KITCPCN 0 <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) 07 <br /> BUILDING CONTRACTOR:, <br /> `< <br /> 'D <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR T 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. -n <br /> I;a N f� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) 0 a V <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m ID Z� <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). y --13 <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 <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. c <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO I <br /> BUILDINGS,ROADS,LAKE,LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N n <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS 0 XJ <br /> MUST BE SIGNED AND DATED BY THE OWNER. to0 1 <br /> o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. c <br /> CONDITIONS OF PERMIT: <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. I per, <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 �vJ <br /> SETBACK AREA. <br /> 5. <br /> Ix R <br /> �� m c H 1 i•9 3 <br /> �1 <br /> 7. 0 H �m <br /> P : <br /> =y : m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c 0 <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of o Eor C <br /> all Information contained in this application(including any accompanying schedule)and I further declare that I recognize U 1 m m : m <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m v <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 unty officials charged with administering county ordinances or other m <br /> authorized person to have access to the q6ove des 'bed premises at any reasonable time for the purpose of inspection. m <br /> m : <br /> M : <br /> SIGN HERE OCT, 9�199f'y <br /> (signet re of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR Q <br /> "(ANN) <br /> N N NfT(J1 <br /> Vt fT O0 N OO <br /> TOWNSHIP PERMITS MAY BE REQUIRED / 0000000 <br /> 0000000 <br />