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Burnett County 74,10 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c a <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d ° <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w P <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. H m <br /> A. A . St N ISSEI- SCLf- a � f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o Z, m <br /> Box 40l <br /> Address Address <br /> WFFA �2 I S`-MA <br /> Cit State, Zi Code City, State, Zip Code <br /> Telephone el � e �$�9 <br /> phone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> ° o <br /> Permit(s)Applied for: �- <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit ° g (n <br /> Zo <br /> N <br /> Accessory Building Sanitary Privy Subdivision ° rn 4' <br /> 9 <br /> 1 <br /> Garage �l /Q�/f/� /�/)�I/`��(',��1 <br /> Structure Use: "" "" ^"'^ I " - "" 'C' o <br /> (family home/ bin, g ge, addition, etc.) OQ J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: X + <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 9 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 0 m A <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within <br /> 300 ft. i $ <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m S <br /> to lake, river or stream, if applicable. ° <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and w ° <br /> dated by the owner. m <br /> PLOT PLAN It N <br /> s d M <br /> PITA NED y <br /> i o N <br /> rJ S�9 <br /> 1. <br /> m <br /> zHoO53 <br /> / e m 1 <br /> `: m <br /> mei C <br /> 8 ` <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- mm <br /> m S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- w 0 N o <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ` V `�ro .0 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ m 8 <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 n u, o <br /> cess to the above described premises at a reasonable time f the purpose of inspection. ' 3 $ N <br /> ac <br /> m 3 n <br /> m V A N <br /> N 0 pp <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) o s <br /> / ,� ) <br /> ZONING ADMINISTRATOR Y, fa eml iVl'"Tb/ <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> $ 8888888u <br />