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Burnett County 7410 Co. Rd. K, No. 102, Siren,W154872 Office of Zoning Administrator m o° o <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> N � <br /> N <br /> J C <br /> OWNER ,) �{ t <br /> Ct <br /> TELEPHONE 7/ °2 7 �( �✓U 7 �` <br /> O <br /> m <br /> HOME ADDRESS „3 r e2 Q S n e �C• r r a e P 6 `� t �`!$3o y`rr � I <br /> m <br /> W <br /> 0 <br /> EMERGENCY/FIRE NUMBER 3od,� ROAD NAME 141 s,Ee-7rT�-v Y2 `t W <br /> QVI <br /> LEGAL DESCRIPTION(see tax receipt) o T (,-7 �n�r, p1 �r rp e'h Ven y/2 q ey V• 11¢9•e ( m <br /> Y o <br /> e <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE K ADDITIO PRIVY El <br /> y ° <br /> TYPE OF PERMIT(S): C <br /> FILLING/GRADING ❑ CAMPING UNIT 1:1 SUBDIVISION <br /> STRUCTURE/ADDITION USE: (moo Y Sh h W'T Stogy „� `�r A/d o <br /> Home/Cabin; Commercial Business; Bedroom; Deck;etc.) c <br /> BUILDING CONTRACTOR: <br /> � ., <br /> CD <br /> v <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/2 X 11 SHEET OF PAPER. ANY INCOMPLETE OR -n 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) T o. <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. t7 m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m m r0 n <br /> NORTH(N). 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. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO <br /> Q <br /> BUILDINGS,ROADS,LAKE,LOT LINES. <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. O` <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT,ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS 2=.C <br /> MUST BE SIGNED AND DATED BY THE OWNER. o 0 <br /> W <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q ° <br /> NEEDED. <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. �1 <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. �J <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 /> 5. <br /> A -anr.-pOt7 � <br /> cp n <br /> am 'i��� <br /> Z : <br /> 7. ? <br /> —rn: m <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 n e <br /> all information contained in this application(including any accompanying schedule)and 1 further declare that I recognizem � <br /> m m <br /> that this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- m '• v <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 to have access to the above described premises at any reasonable time for the purpose of inspection. T <br /> M : <br /> g m : <br /> SIGN HERE <br /> ( gnat re of owner or b i contractor) (date) <br /> 01 <br /> ZONING ADMINISTRATOR <br /> 0000000 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />