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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator ' o 0 <br /> APPLICATION FOR LAND PSE PERMITS <br /> 57 0 <br /> �1A 3 <br /> T 'T52- <br /> OWNER '4j ; MA'Oy :S c� c'd N PHONE n. <br /> �g35 J 76 7 0 <br /> HOME ADDRESS <br /> r � <br /> 0 <br /> EMERGENCY/FIRE NUMBER Z, �y 7,� ROAD NAME ABFeeyL� <br /> 0 <br /> LEGAL DESCRIPTION(see tax receipt) `07—�.7A/^/'G'E.S P1^� E5 4 0J/JI d� \0 k a <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE W ADDITION ❑ PRIVY ❑ I <br /> TYPE OF PERMIT(S): <br /> FILLING/GRA/ y4K�A•&� <br /> DDIINGG EI CAMPING UNIT ❑ SUBDIVISION ❑ n <br /> y <br /> STRUCTURE/ADDITION USE: O <br /> V <br /> ( ome/Cabin; Commercial Business; Bedroom; Deck;etc.) m <br /> BUILDING CONTRACTOR: - f L f ��� <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR n <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O <br /> N fes. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O okZ5 �J <br /> n <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m v <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). C o <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 Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. ° <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO <br /> BUILDINGS, ROADS, LAKE, LOT LINES. O <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 \ 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> NOTE: BUILDINGISTRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN ° <br /> NEEDED. 0 <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 Q� G <br /> ISSUANCE. r <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 THE REQUIRED WATER <br /> 6 SETBACK AREA. chis structure to be used as private residential <br /> ,!7{, Q1 f/ garage/storage only. Not to be used for human 3 a ; Ox n � <br /> 6. <br /> habitation. N y y <br /> Z . 3 <br /> o : <br /> T <br /> - cn m <br /> 1 declare that this application (including any accompanying schedule) has been examined by me and to the best of my 0 p <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of o <br /> c . <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize m 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 <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> CD <br /> CD <br /> SIGN HERE AdOrX W S� <br /> (signature of owner or ding ctor (date) j <br /> ZONING ADMINISTRATOR I� <br /> TOWNSHIP PERMITS MAY BE REQ IRED �/ <br />