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Burnett County 7410 Co. Rd. K, No. 102,Siren,WI 54872 Office of Zoning Administrator v <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> - r <br /> w <br /> OWNER <br /> TELEPHONE Cl lv <br /> MAILING ADDRESS — w ty�� O� <br /> PROPERTYADDRESS <br /> LEGAL DESCRIPTION(see tax receipt) 39— —/ a/�,,- (j <br /> � �C.l T �o <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUC UR ❑ ADDITION ❑ 0 <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION <br /> STRUCTURE/ADDITION USE: CSI&Ip? 3 0 f ,Uk I \ <br /> (Home/Cabin;Comme cial Business; Bedroom; Dec ;etc.) <br /> m <br /> BUILDING CONTRACTOR: m <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 6'/�X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED, m - <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O � <br /> -n n <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. -n o <br /> Z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m 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 rn \ 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. o <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. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <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. o <br /> o � (J <br /> NOTE: <br /> NEEDED. <br /> LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN c ) <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z Ul <br /> CONDITIONS OF PERMIT: o <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT I <br /> ISSUANCE. (� <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. I ((��.. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY ( , , L7 <br /> PERMITTED. W (� <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER "l�'q� <br /> SETBACK AREA. <br /> 5. <br /> 6. m 0 N 8 2 a � m <br /> �O 3 am � z <br /> 7. Z N m o �� 3 <br /> T M <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of d 0 d, <br /> all information contained in this application(including an accompanyingschedule and I further declare that I recognize m - o m <br /> PP ( 9 Y ) g 2 : ; v <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 1 am d <br /> providing in this application. I agree to permit county officials charged with administering county ordinances or other 0 <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection (D Cl) <br /> o : <br /> m m <br /> SIGN HERE <br /> n : <br /> (signature ofbuilding contract <br /> o r or (date) <br /> ZONING ADMINISTRATOR <br /> vi e. <br /> r� fA Eli A di N <br /> N N N OO <br /> VI O (T IT O O <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />