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C1>Ap <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -U o 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> { N a <br /> y <br /> C <br /> *, d \ <br /> OWNER V TELEPHONE <br /> HOME ADDRESS g/s S 4er EJ hod ui*eco Win.lel SJ �a v O <br /> r <br /> EMERGENCY/FIRE NUMBER �� 8� ROAD NAME <br /> r <br /> LEGAL DESCRIPTION(see tax receipt) (TL 3L3 Cs m U6 t� 3q CD <br /> n <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ADDITION ❑ PRIVY ❑ ^ c 0 <br /> TYPE OF PERMIT(S): �J a <br /> FILLING/GRADING ❑ CAMPIN UNIT SUOBDIVISION ❑ pd S. <br /> T. <br /> STRUCTURE/ADDITION USE: G ` o <br /> / <br /> 0 <br /> Home bin; Commercial Business; Bedroom; Deck;etc.) m <br /> � 2 <br /> BUILDING CONTRACTOR: P I VJS Lor. CG, G <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 6'/a X 11 SHEET OF PAPER. ANY INCOMPLETE OR -n 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. 0 ja N .•JJJ <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) `� <br /> �+ v Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m o <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE rnc <br /> NORTH(N). <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 1�1a <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 O <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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. o i <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHEN q <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. <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. l <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 /> SETBACK AREA. <br /> s. S� AQNS►o1� m = 101 y ( ay <br /> om <br /> CL <br /> Cno7 <br /> 7 _ <br /> P : '1 rn: m <br /> I eclare that this application (including any accompanying schedule) has been examined by me and to the best of my GZ C <br /> kn w[edge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy of a <br /> all information contained In this application(including any accompanying schedule)and I further declare that I recognize '" m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m <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 E <br /> providing In this ap ation. I agree to permit county officials charged with administering county ordinances or other ? m <br /> authorized person to pave acces o the above described premises at any reasonable time for the purpose of inspection. T <br /> m : <br /> 40 <br /> t� 4 b <br /> SIGN HERE <br /> (sl at a of wner or buildin o actor) (date) <br /> ZONING ADMINISTRATORv+w v+fn'Afn <br /> N N UIN) N N ut N <br /> N VIOLAOO <br /> O 0 0 0 0 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />