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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (n 1 o / o <br /> APPLICATION FOR — LAND USE — PERMITS 3_ 3 <br /> 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 m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> T�0IV)a iG u �� A(?C Num m = Q <br /> o <br /> f <br /> OWNER (Please Print) n Contr or or Surveyor pr Agent o <br /> X 902 fir^/f 7CG,y ��'0 ?� 3�/OAIA melzagDaJ(�o�, <br /> Adi5ress Atl ress rJ <br /> � 3y 3 <br /> City, State, Zi Code City, State,Zip Colde p <br /> -715 <br /> Telephone II kTelephone <br /> r.r,�wlr�e �GQ �c�iri, <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> `= o <br /> Permit(s) Applied for: 6 �- <br /> Dwelling AdditionFilling/Grading Camping Unit E <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage /!/� / <br /> Structure Use: //0�` Z0 SC-1r�'N) i Cu rc{ <br /> n 5 <br /> (family home/cabin, 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). M <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfield (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 Milt <br /> o <br /> 300 ft. 0 70 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 m � m <br /> to lake, river or stream, if applicable. W 1 To <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I IV <br /> dated by the owner. m 'C <br /> C^ <br /> PLOT PLAN I )-e <br /> IVIc:e+ y G-If,FC <br /> N <br /> A L <br /> l3r- <br /> i ` 1 5creeN N _ I -' <br /> 1 1 �a1,�rcf� o <br /> -Z0 <br /> ro y c�6,N <br /> 225r- <br /> ; DF <br /> r-i2" � <br /> �i ; p F <br /> m o c 2 m m o n F m <br /> m - P•� it afD y <br /> m ' c: 5 m 9 <br /> _ » m <br /> ? 8 [ ae = E M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe 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- i i <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $m $ <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 '. opo : <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> m : a A <br /> m m c <br /> SIGN HERE <br /> (sign ure f own%r or bui contractor) <br /> 1: $ i <br /> ZONING ADMINISTRATOR = "" <br /> NSHIP PERM MAY BE REQUIRED `- N n N <br /> TOWo o m <br /> 221991 ssssssssv <br />