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Burnett County 7410'Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m " 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and a <br /> m c <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 0 <br /> regulations of the State of Wisconsin. H o I 1 <br /> �FN1d15 QS��ACN �bun�e - I�Ie�Sf ��aS� a f <br /> OWNER (Please Print) Con ctor or eyor or A gen m <br /> 115 F_ 'r Rts wt* Zlc,4 O, ax I� <br /> Address Addres <br /> Li-waQWAMt\ MN, 55111 U)k,:, <br /> City, State, Zip Code City,State,Zip Code QJ <br /> Telephone Telephone � <br /> Emergency/Fire No, and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: o °. <br /> w r <br /> Dwelling X Addition Filling/Grading Camping Unit 0 <br /> Z 'o <br /> Accessory Building Sanitary k Privy Subdivision <br /> Garage ) <br /> F pakxLy 4Jor�E - ��;�v;;,a� � � a��, � L)"-J_"4_ " — <br /> Structure Use: <br /> (family home/cabin, garage, addition, etd.)- <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C tN <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 4- <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 /> ON <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 0 '` m <br /> to lake, river or stream, if applicable. M <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 J <br /> PLOT PLAN p I I <br /> SAoRrRt ,+N� •/ N de <br /> qy�F ' ! Jv <br /> r 3 4IF <br /> P m <br /> W y <br /> e- <br /> } ) <br /> TT' IG <br /> 95 <br /> 70 4 vn, <br /> � � 1 <br /> N <br /> T+ZIEfiSf tR� T TREAS V RI- <br /> 13i.1iNb (o3 7Qi ISi jil � <br /> IIS I)S/ m 00 go UWoa m <br /> 1ceoS� re �-,6vd ratf Z ¢@H' : Z o5m3 <br /> 2 M <br /> +�ogD�alA�( CcNTECLINts - ^ : s m <br /> g 2 : <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 1 am responsible for the detail and accuracy of all informs- N m ; o <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor. a f `b'm N <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 g E <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 f <br /> access to the above described premises at any reasonable time for the purpose of inspection. ' m 830 <br /> 0 <br /> v A e <br /> A : W <br /> H in <br /> SIGN HER <br /> (sign t e ogbwner jr buildin tractor) I1rl L <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRE II II APR - g i jo <br /> LL� 888888 <br />