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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m - -- <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> located a3 shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the M = 9 <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. _ o <br /> � Arr,� /�� .tivil✓y Gr�,�/�.- A�hl r �rPc rI� a o <br /> NER (Please P int) / Contractor or Surveyor or Agent o <br /> A <br /> ddresA .On <br /> JJ// Address ,/ � <br /> (�r_ Nravp NGl r �2 Uh�771` /1�di 71� �T^Ary N. /lam 4S <br /> City, State, Zip Code 6 i City, State, Zip Code <br /> Telep %'QAV�2 t: yh a/ /.Teleph/e .Z, lick,7V_ 7 '� '� O <br /> Emergency/Fere No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> o < L� <br /> J <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit 0 ° <br /> v <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage P <br /> 6/��' I� / <br /> Structure Use: I dle 8LJjlI�� (9g` y� <br /> (family ome/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: O <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). Q o <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 11 9 v, <br /> 300 ft. In Z `c <br /> 4. Show dimensions in feet of the f ollowing:(a) building to all lot lines,(b)building to center line of road,(c)building 3 <br /> to lake, river or stream, if applicable. m o <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. H <br /> m <br /> PLOT PLAN (� <br /> 0) <br /> 0 <br /> J <br /> N <br /> 0 �J <br /> O � <br /> N 1�Vvv1^1v\) <br /> » I <br /> Z <br /> n � <br /> G <br /> o c -° 9 0 D D O m <br /> a <br /> ' & N a m a <br /> < wE <br /> 0 Zi <br /> o s J : T v a <br /> m <br /> S : m c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa- fn w fn O <br /> lion 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. I 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 ^� <br /> u <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m 3 $ <br /> SIGN HERE <br /> gna re of owner bu' Ing contract (date) i <br /> o x <br /> ZONING ADMINISTRATOR $ <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> Moo N 8 8 9 m <br /> $ $ $ $ $ $ $ $ N <br />