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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 c) Z <br /> APPLICATION FOR LAND USE PERMITS 2. <br /> r <br /> ir <br /> OWNER .�' o,RERT Dr 01^S C) NTELEPHONE o <br /> m � <br /> / r( 1^ 7�,- � 3 s-gs r q \' W <br /> HOME ADDRESS a7 6 7 O L— R v^ S P 00 N ER \AJ 0 1 0 <br /> EMERGENCY/FIRE NUMBER a010L 0 � I I "C( ROAD NAME � 0 m <br /> LEGAL DESCRIPTION(see tax receipt) L o T 3 G S M V P 113 PGL 60\1 I-©T4 <br /> N <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE X ADDITION ❑ PRIVY ❑ N o '-+- <br /> TYPE OF PERMIT(S): c 4- <br /> FILLING/GRADING <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ n <br /> STRUCTURE/ADDITION USE: .S 1 V t'�I�CS�'�. 0 � Q <br /> (Home/Cabin; Commercial Business; Bedroom; Deck;etc.) N �, <br /> L � <br /> BUILDING CONTRACTOR: ,✓K. r'F ONEr <br /> 1 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR R G � <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. O <br /> M i 'Q pi <br /> DIRECTIONS FOR PLOT PLAN DRAWING- (AERIAL OR TOP VIEW) O `e <br /> 0 a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. Z <br /> m � � � <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NS)AND INDICATE <br /> NORTH(N). <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. 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. `y <br /> S. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N Sv 00 <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER, BUILDER,CONTRACTOR,ETC.,THE PLANS m <br /> MUST BE SIGNED AND DATED BY THE OWNER. o _ <br /> t 9 <br /> � vl <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q <br /> NEEDED. CA 2 <br /> it <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. e <br /> CONDITIONS OF PERMIT: p C) <br /> C) <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> 91C- � , <br /> ISSUANCE. ►� <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. J1 C <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. J '- <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER O <br /> SETBACK AREA. O <br /> 5. y <br /> A O L O <br /> n m <br /> 6. o' NCioa9' 3 <br /> 0 <br /> T Z ' Nil m � <br /> o : <br /> = y: <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c p <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of m E C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize ' 'm E ;a <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- o <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 permit county officials charged with administering county ordinances or other m <br /> authorized person t ave access to the above described premises at any reasonable time for the purpose of inspection. m <br /> SIGN HERE v�U" "�.. 3� ��11 [[�� <br /> (signature of owner or building contractor) (data) "> <br /> Rj <br /> ZONING ADMINISTRATOR <br /> I R�k�e%J DISon s-3-II moo . ; ; <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />