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(" Cmv, <br /> eurnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator -0 o 0 <br /> APPLICATION FOR LAND USE PERMITS . <br /> H ° VQ <br /> �/ M o <br /> OWNER / fgrk p�^^ TELEPHONE <br /> m <br /> HOME ADDRESS 122 y �o�rn,'na DOJP /'CCTef�Lt W� ) [�✓� _ r V, <br /> 0 1 <br /> EMERGENCY/FIRE NUMBER 87 2 y ROAD NAME O ( 1 <br /> oHr„�n'l o✓P <br /> � r <br /> LEGAL DESCRIPTION(see tax receipt) c <br /> C <br /> TYPE OF PERMIT(S): DWELLING/BUILDING-GARAGE/ACCESSORY STRUCTURE DDITION v <br /> o. <br /> S. <br /> E. <br /> SANITARY PRIVY FILLING/GRADING CAMPING UNIT SUBDIVISION (0 <br /> r N <br /> 1 <br /> STRUCTURE/ADDITION USE: or <br /> (Home/Cabin; Comh4rcial Business; Bedroom;Deck;etc.) <br /> A PLOT PLAN MUST BE PROVIDED ON A SEPARATE SHEET OF PAPER. ANY INCOMPLETE OR <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. _n <br /> � w <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) r <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). N .. 3 <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES, (B)BUILDING(S)TO m v <br /> CENTERLINE OF ROAD, (C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF LAKE, Z <br /> STREAM OR RIVER. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO BUILD- <br /> INGS,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 I <br /> MUST BE SIGNED AND DATED BY THE OWNER. (o' L,))o <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE '” c <br /> ISSUED. 2 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <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. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4, NO STRUCTURES, INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN 75 FEET OF THE OHWM OF LAKES, <br /> PONDS, RIVER UNLESS SPECIFICALLY PERMITTED. <br /> 5. <br /> 6. � n A <br /> a 9 C N N 0 7 3 <br /> 7. Z : ? i 70 <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 ofa C <br /> all information contained in this application(including any accompanying schedule)and I further declare that I recognize o m E <br /> M <br /> that this Information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is- <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 <br /> authorized person to have access to the above described premises at any reasonable time for the purpose of inspection. -n <br /> C : <br /> C5 ; <br /> SIGN HERE 17 Oct <br /> (sIgn!t!q!je of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR 1 M - Ian( /I 71 <br /> H fA fA 44 44 fA H <br /> N N N N "Cn <br /> OI lT 0 01 01 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />