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(_to'v) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 'u o 0 <br /> �' v <br /> APPLICATION FOR — LAND USE — PERMITS m 3 � uy <br /> TO THC'ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and c ,\ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m Y <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. y m <br /> �/t9R E.S A . /12AG0SoAJ g to <br /> f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o � <br /> dy7as AA/clfo2 Z&IV RD <br /> Address , Address <br /> Ind.-r3s �� It 49 r _ S-gpy g <br /> City, State, Zip Code City, State, Zip Code <br /> V2 - _-Z <br /> Telephone Telephone <br /> sq" — <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> o M <br /> Permit(s) Applied for: c <br /> 0 <br /> 0 <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building V Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: ��l �-n��daP' 3{vd-, /a <br /> /�-C�0/ <br /> r <br /> (family home/cabin, garage, addition, etc.) 0 <br /> � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 Q� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X I\ <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (DF). 0 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 'P m <br /> 300 ft. Z `c <br /> 4. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building c <br /> to lake, river or stream, if applicable. M 4 o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C o <br /> dated by the owner. m <br /> PLOT PLAN (�O <br /> 1 C <br /> ur <br /> I � <br /> 0 <br /> E �che� �►-a�,v) <br /> w <br /> Z <br /> 9 <br /> I� <br /> _ ff m <br /> a m a <br /> S in A <br /> Z q .02 <br /> P `i T a <br /> ZZ m <br /> o <br /> s a= _M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- "` o ; m : ; <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all Informs. 'c ` ' yy!� G):y:; : p <br /> tion contained in this application(Including any accompanying schedule)and I further declare that I recognize that this Infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin In determining whether to Issue a permit. 1 8 m g ; <br /> further accept all liability which may be a result of the County of Burnett relying on this Information I am providing In this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have O j <br /> access to the above described premises at any reasonable time for the purpose of Inspection. <br /> T � 8 <br /> SIGN HERE <br /> (signature of owner, uildin contractor) (date) <br /> [ o : <br /> ZONING ADMINISTRATOR g <br /> M <br /> TOWNSHIP PERMITS MAY BE REOUIRED $ o o�" m <br /> 88888 89ai <br />