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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c f o <br /> APPLICATION FOR — LAND USE — PERMITS m o <br /> TO THE 70NING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <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 _ <br /> regulations of the State of Wisconsin. <br /> "Tom 501-%'Ayar 5 we C•t_v..w.elJ TtA#-r9efJ 4- wq Lo a 0 <br /> OV I ase Pri t) Contractor or Surveyor or Agent m <br /> `1 IIv tJq P.r� _�2 DeJtI.S <br /> Address Address 1 <br /> City, State, Zip C de City,State, Zip Code <br /> ��r63o 54993 ,K) Q <br /> Telephone Telephone <br /> hfs- AG6 - '71x4 S <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s) Applied for: e 0 <br /> 0 <br /> N Or <br /> Dwelling Addition Filling/Grading Camping Unit S <br /> Z <br /> 0 <br /> Accessory Building Sanitary Privy Subdivision P $ <br /> Garage <br /> Structure Use: a la7 \AOVAQ, o <br /> (family home/cabin, garage, addition, etc.) (� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: o 1 <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 (yi),septic tank (ST),and drainfield (DF). C B <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 v <br /> 300 ft. o $ <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, If applicable. 1'f <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. m � S <br /> PLOT PLAN <br /> I_ <br /> t <br /> o <br /> m <br /> LA <br /> jj <br /> )} (��tcrfye 'ter e g f03 0 s� <br /> %tge <br /> N�e—�51Q�fel �o r�� % fir n 3 <br /> T,e,r t tdo m d <br /> g a <br /> ✓ ��� <br /> _ <br /> ? <br /> arc('/��n'hntc�i • <br /> �uliQl7R Cle,40H <br /> 1 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 1 am responsible for the detail and accuracy of all Informs- <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. I 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 <br /> access to the above described pr Ises at any reasonable time for the purpose of Inspection. m 8 P <br /> v A y E <br /> _tom[x _90 <br /> SIGN HERE ~ a <br /> (signs of owner or buildin contractor) rl C� `/�`- r' ( ¢ '• ' <br /> ZONING ADMINISTRATORio'NalliJ <br /> e ; <br /> TOWNSHIP PERMITS MAY BE REOUI <br /> i 888 8 <br />