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- I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE 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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. <br /> DOF-( + L Uv M 044 7Sf)) ��� � a � f <br /> OANER (Please Print) ' Contractor or Surveyor or Agent <br /> 50319 / "l VlP_YVo led <br /> AD�rress Address _ <br /> LJanburW . 5yb'3a I <br /> City, State,Zip Cu e City, State, Zip Code <br /> I <br /> Tel Telephone <br /> /� ;� Telephone <br /> Jo31 MlAueev'( RC Q <br /> Emerency/Fire No. and Road Namb <br /> �y — 5wYy !v <br /> Legal Description (as Indicated on tax statement) o <br /> G) <br /> Permit(s) Applied for: o` ° Qj <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit 0 °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P $ <br /> Garage <br /> 1 <br /> I <br /> structure Use: <br /> (family home/cabin, garage, add on, ) <br /> etc. � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 211 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). C) 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 an P <br /> 300 ft. o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building y <br /> to lake, river or stream, if applicable. fA 0 !r1 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. FB <br /> PLOT PLAN <br /> o <br /> I? " o <br /> 0 <br /> IIII�N'J�' <br /> y ?. <br /> m <br /> w` <br /> \04 70 <br /> �� Z <br /> lT' <br /> Ll 0 Ao-C PAt-,-( (fie kHadl ,! 6/µl t.t f1,l\) � <br /> m o c m m o a F m <br /> p1CHoM - <br /> 13�0 Z < « zWQ - <br /> 0 Ti : M <br /> `- m <br /> Cc <br /> n1 C <br /> g <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- [ o E m 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- yy!! w E O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this init. 1 9 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permt. 1 i g m <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- y, <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> 00 : <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m 8 n <br /> m A e <br /> lD- /v - 9d » ` ; <br /> SIGN HERE <br /> gn ture of o r or building contractor) (date) <br /> ZONING ADMINISTRATOR g <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIRED G Pn�rn o o 8 m <br /> 8888 $ $ $ 8 a) <br />