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' /" <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m M o a <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> TO THF ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2N v \ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m C <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 o. <br /> regulations of the State of Wisconsin. m <br /> m <br /> kletway M <br /> WNER ease Print) f7 CoM[�ctorpr Surveyor or Agent v m <br /> G� �� U "ELS oC - lomch,, �2 , <br /> AddressAddr s <br /> i '0rj PSSP C A), I <br /> Cit State, Zip C� City, State, Zip Coe Y <br /> y715 -- 3V9- ;7 <br /> Tel hone Telephone <br /> 5650 l.wke vlek-o 2Q_ <br /> Emergency/Fire No. and Road <br /> Lei is .ate 3 6_ss A1c� <br /> Legal Description (as Indicated on tax statement) <br /> � c> <br /> Permit(s)Applied for: 0 <br /> Dwelling Addition _X_ Filling/Grading Camping Unit S <br /> v <br /> y Z 'o <br /> Accessory Buildin Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: ✓PlC <br /> (family home/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). 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 3 <br /> on 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within on <br /> a c <br /> 300 ft. o a <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. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and Cy <br /> dated by the owner. fA <br /> PLOT PLAN _5' A�-g L9 <br /> 0 <br /> 0 <br /> N <br /> v � <br /> N � n <br /> T <br /> o c m m n n g m <br /> c an� �nN ami <br /> ZH0, 3' c 3 <br /> O ?IN: M <br /> Gi 3 o <br /> $ i ate : M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- rnI"t-1 o m `� m <br /> edge and belief it is true,correct and complete.I acknowledge that I 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- `.b'ro v, [ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m <br /> further accept a liability which may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. I agre to permit county officials charged with administering county ordinances or other authorized person to have <br /> O ' [ <br /> access to the Ove des ' d prem' sat any reasonable time for the purpose of inspection. m 8 <br /> T 3 A H <br /> m m a <br /> � 7 �C,O `� O H8 [ <br /> m <br /> SIGN HE E I ure of o or building contractor) ate) s <br /> ,x^ o <br /> ZONING ADMINISTRATOR ° 8 ' <br /> � bl dlHNiRWdIT <br /> TOWNSHIP PERMITS MAY BE REQUIRED r N N 8 8 8 m <br /> 88888888CMD <br />