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w( W� <br /> Buri„tt County 7410 Co.Rd. K, No.102,Siren,WI 54872 Office of Zoning Administrator CD < c <br /> APPLICATION FOR LAND USE PERMITS p <br /> OWNERP�� Il /4 G( TELEPHONE -31 p r <br /> .ate )J 11 / / 1l°R <br /> G� m <br /> MAILINGADDRESS ] g£{9 Xd)k e X4� 4/Pl3 - <br /> o <br /> PROPERTY ADDRESS ,2 gIf .f /fd/6l e tf tri e13 <br /> LEGAL DESCRIPTION(see tax receipt) S��l7`L�a l R /�, 4/ 1 of 6 /i"OD`j/ e /�Vo � <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION Hl— 0 <br /> TYPE OF PERMIT(S): a <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION El S. <br /> -9 <br /> ge � a <br /> STRUCTURE/ADDITION USE: G'0�1Q 'C <br /> (Home/Cabin;Commercial Business; Bedroom; Deck; etc.) <br /> BUILDING CONTRACTOR: <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR T 2 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 y <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m M <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE mo <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m a <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 I (� <br /> BUILDINGS,ROADS, LAKE, LOT LINES. �cJ <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. (��J <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONT / TC.,THE PLANS 3 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. 1 �0 o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFIG"T <br /> N MAY BE <br /> NEEDED. a <br /> ,' <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. J�` `� J /; c <br /> CONDITIONS OF PERMIT: BORNE "T l <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ZQ/COUNTY / <br /> ISSUANCE. NG <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 /> 5. <br /> SETBACK REAM. <br /> 3) dw>0n0m <br /> m 3 am xam <br /> 6. mCHyo77+ <br /> Z m p 7 C <br /> 7. P i it z i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of n <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 E <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 r o '• <br /> authorized person to haveAccess to the above described premises at any reasonable time for the purpose of inspection. T m o <br /> m m <br /> SIGN HERE - <br /> ` m <br /> (signature of or or building o r-actor) 1 (date) `• <br /> a: <br /> C f'1/ U� <br /> ZONING ADMINISTRATOR 1�3 i Ln <br /> ``vv/I N�� N N O <br /> e OL� TOWNSHIP PERMITS MAY BE REQUIRED 1 N �(W��� <br /> (�.Z TWIS PERMIT SHALL EXPIRE ONE YEAR FROM DATE OF ISSUANCE 7 <br />