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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0 -- a <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <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 0 <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 /> amire2 J3,�d4 a o <br /> OWNER Please�P(int) t Contractor or Surveyor or Agent o � <br /> .� ��n (J0.kjG r'eC/l 4y. S6. °' V, <br /> AddreVo/?, Yin/. 5 snnl Address <br /> J <br /> City, State,Zip Code City,State,Zip Code <br /> C6 /2- X36 - kar l(o <br /> Tele one Telephone J <br /> 7�6 �)6mOSoY� 6Djj �( of <br /> Emergency/Fire No. and F1ad Name <br /> Legal Description (as Indicated on tax statement) - <br /> c> <br /> Permits)Applied for: o °< Qj <br /> Dwelling Addition Filling/Grading Camping Unit g o _ <br /> 0° O <br /> Accessory Building ._G1,— Sanitary Privy Subdivision � <br /> Ir <br /> Garage <br /> Structure Use: SfOr([G� r <br /> (family home/cabin, garage, addition, etc.) Will <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <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). () 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 P <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. m , 0 <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 <br /> PLOT PLAN W <br /> N0. Surl4 LC K <br /> �1 9� <br /> �—T <br /> 0 <br /> 0 0 <br /> � 14/' � I $OrSe�bacK `� <br /> .T N.!1• n <br /> o_ N Z <br /> a sr <br /> rb <br /> r <br /> D o c m ? D Dao M <br /> F m <br /> Z m' o m,z M <br /> m <br /> U 8 ac : M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o '� `� m <br /> m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- w G) 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 ' 8 m 8 <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- N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have O o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m <br /> m 3 n <br /> m V A m <br /> ♦ 9 � m y <br /> SIGN HERE <br /> gnature if owner or buil g contractor) (date) <br /> ZONING ADMINISTRATOR J"S P. F-0tilgao ' g <br /> TOWNSHIP PERMITS MAY BE REQUIREDN m <br /> 88898 $ rmn <br />