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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and N U) <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. y m <br /> / m � <br /> TAOM05 M . Gree-0 n f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> / 3 ? 9 TUND <br /> 'Ps <br /> Address <br /> ST Pau ! MN 55/11,0 <br /> City, State, Zip Code City, State, Zip Code <br /> Telepho p^ Telephone 7 <br /> keUSk / 9�"I 6aa1t' Ln - <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n O <br /> Permit(s)Applied for: 0 o <br /> m � <br /> o d. <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 'o <br /> Accessory Building SanitaryPrivy Subdivision P <br /> Garage \ <br /> Structure Use: `r ONIAr <br /> 0 <br /> (f4nily home/ca in, garage, addition, etc.) <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). <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 c <br /> 300 ft. o n <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 1111 <br /> m' <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 CC <br /> dated by the owner. 0 <br /> PLOT PLAN NORTH (S <br /> - <br /> 0. <br /> — <br /> E <br /> *we m' <br /> R <br /> K PR)v y q5' �} f1111 <br /> E , I = 3X VV <br /> D <br /> _._ =. m n m <br /> LJA�F <br /> 05- � mo0. ro3 <br /> oZ c <br /> F " : N 9 <br /> 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 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- w m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- f $ ro N <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 O a o <br /> access to the above described premises at any reasonable time for the purpose of inspection. if <br /> 8 0 <br /> A m <br /> SIGN HERE <br /> (signature of ner r uildi actor) <br /> ZONING ADMINISTRATOR <br /> NSHIP PERMITS MAY BERF�1 f�``4EDAPR 2 4 �t " <br /> �nrr I .7� rii NN �aoo � m <br /> ;�� ��,1 rlll gSg888ggN <br />