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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o P <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a i <br /> tions of the,State of Wisconsin. m o <br /> onaldl �ia.' �Q l e:+��re braAC Lew%W',e = o <br /> OWNER(Please Print) Contractor Surveyor or Agent n f <br /> HloS N1r+cv P�aac RE 1 �nx ,11D d m <br /> Address Address =° I Q <br /> 5tiore.�rew !"11�1eso�a )gos's <br /> City,State,Zip Code City,Skate,Zip Code <br /> (LIQ 483 - iall (SIZ) 41- SI'd7 �u (715656 3 50 <br /> Te eI phone V'4e L�4 Telep oh ne 3 <br /> 6641 I li ti e �u p <br /> 4 E ergency/Fie No.and RoadName I/ <br /> jiQrc,e ah SEPI of /VEYN eF Sec.s�Tb�� I� I� T <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit .`.- <br /> '� r <br /> Addition Privy Moving Subdivision 0 o <br /> IInn 'a f <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) <br /> Directions for plot plan drawing: G <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). o <br /> 2. Show the location of the well(W) septic tank(ST), and drainfield(DF). �} <br /> 3. Show the location of any lake or flowage- if within 1000 ft.and the location of any river or stream -if within 300 ft. 11 <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> 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 dated byO o <br /> the owner. 3 <br /> 71a N <br /> PLOT PLAN Z `v <br /> M o <br /> Mwc r�a �lce w <br /> m <br /> � n <br /> UI <br /> i A = <br /> G y <br /> i <br /> 43' <br /> $Ir N N" <br /> o <br /> m <br /> o � <br /> V <br /> G Z <br /> OeaG aid" rn„s io <br /> A (0-ur9r DD <br /> m m ':n� <br /> w 2 m o m <br /> Z of ifDZ1 <br /> � i � o <br /> I Be are that this application(including adny accompanying schedule)has been examined by me and to the best of my knowl- c i f m m y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- t A? m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- N$N C) <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I : <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 ij <br /> access to the above described premises at any reasonable time for the purpose of inspection. m w» o <br /> m : 3 Ow i <br /> 1 �.0 rn : in m i, <br /> SIGN HERr/;4;14 � 6 � r7 i �':° $ i <br /> (sure of own building contractor) (date) P i : <br /> o: <br /> ZONING ADMINISTRATOR ` 4-n <br /> NoNInWNSHIP P RMITS MAY BE REQUIRED �. p+� In <br /> Qaaa <br />