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I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR LAND USE PERMITS 3. <br /> r <br /> m O <br /> DA <br /> m 0 <br /> OWNER O t.Q Vr6! 6 DA- ,dc- TELEPHONE 7i3'-_ .269-39/0 o s <br /> m <br /> MAILINGADDRESS a i 5 LKS O /JN Ur( W ,f' �? O <br /> PROPERTYADDRESS <br /> 0 <br /> LEGAL DESCRIPTION(see tax receipt) S 0 7 Tyonl ,. Ytry 14,4 - _ <br /> fpr <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSCIRY STRUCTURE.1',I ADDITION ❑ rp o <br /> TYPE OF PERMIT(S): c � <br /> a <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ ;SUBDIVISION ❑ �, <br /> STRUCTURE/ADDITION USE: <br /> (Home/Cabin; Comn)ercial Business; Bedroom; Deck; etc.) m <br /> m <br /> BUILDING CONTRACTOR: .22. <br /> m <br /> v 4 <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 S EET OF PAPER. ANY INCOMPLETE OR T 3 O <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. CI -� <br /> M Qi <br /> DIRECTIONS FOR PLOT PLAN DRAWING- (AERIAL OR TOP VIEW) p m <br /> -n a <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOW OR DRAWN TO SCALE. ? <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILD IN S(EB)AND ALL NEW BUILDINGS(NB)AND I DICATE <br /> C.) p <br /> NORTH(N). C 0 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUIL ING(S)TO ALL LOT LINES,(B)BUILDING(S)T m a <br /> CENTERLINE OF ROAD,(C)BUILDING(S) MEASUREMENT T I THE ORDINARY HIGH WATER MARK(OHWM) F y� Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLA D AREAS. C o <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(STJ AND DRAINFIELD(DF),AND ALL DISTANCES 70 <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.,THI PLANS 0 <br /> MUST BE SIGNED AND DATED BY THE OWNER. <br /> f <br /> 0 2 <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED $O AN ONSITE VERIFICATION MAY BE DONE V HEN a g W <br /> NEEDED. 51 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: P O S <br /> I 1 <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT W C� <br /> ISSUANCE. O <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. O <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWE UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> 6. 0 a0M0 mm a :E M <br /> vomcy . o`" � 3 <br /> 7. Z c y o 2 <br /> P m <br /> I declare that this application (including an accompanyingschoule has been examined b me and to the bet of my D <br /> PP ( 9 Y ) y <br /> knowledge and belief it is true, correct and complete. I acknowle ge that I am responsible for the detail and acc racy of m cn N C <br /> all information contained in this application(including any accom6ranying schedule)and I further declare that I recognize [ m m <br /> that this information I am providing will be relied upon by the Co4my of Burnett Wisconsin in determining wheft or to is- i <br /> sue a permit. 1 further accept all liability which may be a result of the County of Burnett relying on this Informal on I am <br /> providing in this application. I agree to permit county officials charged with administering county ordinances r other <br /> e : 1 <br /> authorized person to have ces to the above described premi�ateasonable lime for the purpose of inspection. m 2 <br /> T 6 <br /> SIGN HERE m D <br /> a : <br /> (-sig�nat-ure of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> d ONO VwiUNO <br /> TOWNSHIP PERMITS MAYBE REQUIRED <br /> THIS PERMIT SHALL EXPIRE QNF YEAR FROM DATE OF ISSUANCE <br /> �P to �!-1 -D? <br />