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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) m -- 0 <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 5 V� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the O <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulationsof the State of Wisconsin. y m <br /> V\ t <br /> Y'"' j� ase Pnmy, f - Contractor or Surveyor or AgentqY <br /> o <br /> m <br /> Adcl� as <br /> Jf <br /> Address <br /> CO3 StatZip Code City,State, Ip Coe <br /> �0howQ <br /> , r .J 1 -�l t•. .-J �' E/ �-`rt <br /> T — Telephone' <br /> v_ <br /> O J <br /> Emergency/Fire No. and Road Name <br /> egal Description (as Indicated on tax statement) o <br /> pp (� <br /> 0,T ') cJY , 4t /1, Z, J7rOr jx .c2D, �,u YC'M, ka�< /'�G r..>.t / i'� o 0 <br /> Permit(s) Applied for: o` <br /> 0 — <br /> �' r <br /> Dwelling Addition Filling/Grading Camping Unit o °- <br /> z o <br /> Accessory Building _ Sanitary Privy Subdivision P <br /> Garage J P i <br /> Structure Use: 'j`df P i i t� r.' <br /> (family home/cabin;garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X 0 <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 11 <br /> 300 ft. millz Q <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c) building n P n <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 <br /> dated by the owner. (4 <br /> PLOT PLAN ---- -- ---�-- <br /> cn <br /> lj5 I <br /> }— s <br /> I �v <br /> 9 <br /> 0 <br /> N <br /> R » I <br /> Y- <br /> w <br /> Z <br /> r, D r� rn � rDr DD 0 <br /> O c o m n a <br /> M <br /> 0 00 <br /> z <br /> /:• i� '_� P F o T D <br /> m <br /> g ' m m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know)- 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- O <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 Y•-' g 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 u, <br /> access to the above de .pfemises at any reasonable ime for the purpose of inspection. m g <br /> m 3 8 <br /> i <br /> m m v <br /> SIGN HERE i .l ;-o, c�/ :, // .n E a 8 <br /> -!` <br /> is <br /> ure of own o iding contractor) <br /> o : FV : <br /> ZONING ADMINISTRATOR 't j�G! � 8 ' <br /> TOWNSHIP PERMITS MAY BE REQUIR 2 Q � N N N N p S m <br /> Lv 88888� N <br /> 88 <br />