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01(�-C)-n ' <br /> Burneak County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 o o <br /> APPLICATION FOR LAND USE PERMITS 3 <br /> 0 o ' <br /> m � 7wC� <br /> c <br /> OWNER (XC ` (lk TELEPHONE��� <br /> HOME ADDRESS J�� 1�/� / q 7 0 <br /> co <br /> EMERGENCY/FIRE NUMBER �,��1�� ROAD NAME ,Y)e,f q r� <br /> LAI <br /> LEGAL DESCRIPTION(see tax receipt) S\AA 1/� S —<;IOeV%on 1 yk N-1Z \uaV A )^ m <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION PRIW ❑ w o <br /> TYPE OF PERMIT(S): <br /> FILLING/GRAD ❑ <br /> FILLING/GRADING CAMPING UNIT ❑ SUBDIVISION El 5 <br /> T1 <br /> STRUCTURE/ADDITION USE: 'C n 1 r" l a <br /> ome/Cabin, ommercial Business; Bedroom; Deck;etc.) y <br /> \ 1 <br /> BUILDING CONTRACTOR: �1 C VA CL(3L Y`\l]lA—) <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. T r. <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) p <br /> 'n a <br /> 1. o <br /> Z <br /> 2. In <br /> 3. )TO m 3 1 <br /> 100000MORMNENT TO WETLAND AREAS. )OF 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 <br /> MUST BE SIGNED AND DATED BY THE OWNER. to <br /> c <br /> o � I <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAY BE DONE WHENa 0 <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: ° �J <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. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY I <br /> PERMITTED. <br /> NC- <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER Q <br /> SETBACK AREA. <br /> 5. <br /> ,p 7. m m <br /> m C!n 41 0 j r. <br /> 7 <br /> 7. MW <br /> C N =II r� <br /> = i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my Zj cy p <br /> knowledge and belief it is true, correct and complete. 1 acknowledge that I am responsible for the detail and accuracy of m C c <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize )E CL <br /> o m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- t7 <br /> sue a permit. 1 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 i m <br /> authorized person to a cess to the above described premises at any reasonable time for the purpose of Inspection. <br /> r : <br /> (D : <br /> m : <br /> SIGN HERE Lq — �� <br /> (signature of ner or building c t)cptor)�� (date) i <br /> ZONING ADMINISTRATOR <br /> N N(T N Nfll(T <br /> (71 f710(T fT 00 <br /> TL.NSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />