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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d --0 <br /> APPLICATION FOR — LAND USE — PERMITS . <br /> d 3o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ( n <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. o C <br /> �I k(I ?R OWC- EN SELF m o <br /> O ER (PI ase Print) ` Contractor or Surveyor or Agent 1 V, <br /> 15t 1CLQQ- �. W r o <br /> Address U <br /> f Address <br /> _.F-Gy Ci.--�\�E� . Wx J'N � <br /> 9n <br /> City, State,Zip Code ICity, State,Zip Code <br /> 715 - 4i32 - $502 1 �� <br /> Telephone Telephone <br /> X1725 �fl. '�AP�E_S LK. P <br /> Emergency/Fire No. and Road Name ) <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s) Applied for: o <br /> r irv\, <br /> Dwelling Addition Filling/Grading Camping Unit 6 °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: I�t l r1�( ( 00 �U <br /> ilbs <br /> (family home/ abin, garage, addition, etc.)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). <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 m <br /> 300 ft. z `c <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building P 3 <br /> to lake, river or stream, if applicable. fA I o �?1 <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 SZ/ <br /> RRc N Eta <br /> IT <br /> 0 <br /> 0 6, <br /> o <br /> b <br /> W <br /> n1..�� <br /> --L.� Z <br /> y <br /> 7J r 0 C m 0 P D D * M o c m � n f m <br /> < � zHo3 <br /> z mo o : g n � <br /> P f T y p <br /> — m <br /> 8 € c ' <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know,- -^' e m I 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 informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor� 8,0 <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 al, liability which may be a result of the County of Burnett relying on this information I am providing in this <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have vI <br /> access to the above described premises at any reasonable time for the purpose of inspection. v g <br /> m 3 <br /> N V A m <br /> A N 8 . <br /> W N <br /> SIGN HERE <br /> (at azure ofowner lding contractor) (date) <br /> ✓ o : <br /> ZONING ADMINISTRATOR <br /> / �eio wwwm <br /> (/ TOWNSHIP PERMITS MAY BE REQUIRED u v 'o o d m <br /> 8888N <br />