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Burnstt County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator m o c <br /> APPLICATION FOR LAND USE PERMITS 3, <br /> r <br /> y O <br /> N <br /> M � p /l / d <br /> OWNER r l T— ZZ 5 P6Y '� TELEPHONE �j`pE'p '6 9?SIF <br /> b <br /> 3F 7 3 fi� Ys coz4r �� e7 1- O <br /> HOME ADDRESS "]�,. � � ^ <br /> N <br /> EMERGENCY/FIRE NUMBER oeoy�S ROAD NAME <br /> LEGAL DESCRIPTION (see tax receipt) i4? Cov &yz <br /> DWELLING/BUILDING 1:1GARAGE/ACCESSORY STRUCTURE,IaI ADDITION ❑ PRIW ❑ a ° <br /> TYPE OF PERMIT(S): rr <br /> FILLING/GRADING ❑ CAA PING UNIT ❑ SUBDIVISION [❑� ! �, <br /> STRUCTURE/ADDITION USE: V q� 4*i j I/.J',\/� T 0 <br /> (Home <br /> Cabin; o mercial Business; bedroom; beck;etc.) m <br /> BUILDING CONTRACTOR: John �� �z6 <br /> v <br /> CD <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O o T <br /> In Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. C1 oOi p <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m I <br /> NORTH(N). N o <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. c <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. <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. <br /> o qj <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHENa <br /> NEEDED. 2 I <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o O <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ` l <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 <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA.5. n- <br /> &3406 <br /> -- �p-70 f l0 O�l Il�� m - on, r ��am <br /> ,��, <br /> Eir Vl�cn �e� m m <br /> 0 � m c m . o � 3 <br /> � J V I Z y � � 79 � <br /> 7. O <br /> _m: m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 6 c p <br /> knowledge and belief it is true, correct and complete. I acknowledge that I am responsible for the detail and accuracy ofCL <br /> C <br /> all information contained in this application(including any accompanying schedule)and I further de re that I recognize . <br /> that this information I am providing will be relied upon by the Co g whether to is- O <br /> sue a permit. I further accept all liability which may be a result o I 'nformation I am m <br /> providing in this application. I agree to permit county officials 59EVIcr <br /> r inances or other Co <br /> authorized person to have access to the above de Mod premise any reasonable time for the pu se of inspection. T <br /> CD <br /> AUL - b 199& CD <br /> SIGN HERE 4& <br /> (signature of wnerrorr}buuildiingcontrgURNETT COUNTY <br /> (date) <br /> ZONING ADMINISTRATOR 1(Y) f Ily7)1 l 'OAtlNG v+ <br /> • tntnwfnfnw-• <br /> N !A P N N(n (n <br /> Ot Vt O N01OO <br /> 0 0 0 0 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 000000 <br />