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CF�( <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator cm o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> m 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 5 <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 _ <br /> regulations of the State of Wisconsin. m ,� <br /> m <br /> LZ2i e Gagn Pr 7' Pik-- Ren r/ Con.; f• a o <br /> 0VP ER (Plea a Print Co tractor or S eyor or gent m 4f <br /> Gtati fJ /err; . ��9k <br /> Address Ado <br /> �J er %J- <br /> City, State,Zip Code City, State,Zip Cod <br /> Telephone Telephone C� <br /> i <br /> Emergency/Fire No. nd Rpadti Namenl� 6 � 00 <br /> Legal Description (as indicated on tax statement) <br /> Permits) Applied for: o <br /> 0 <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary V Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) '1✓" <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 O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 3 <br /> on 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream-if within <br /> 300 ft. 11 Z <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building A <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 I <br /> dated by the owner. m <br /> :/ <br /> PLOT PLAN S <br /> �(} 1 I� <br /> C. e <br /> cn <br /> Paw j :b <br /> J <br /> m <br /> w <br /> nn �lga3� F <br /> 'Dee 1 T <br /> A o c m m n n V m <br /> A. Da� .'aaN a1D9 <br /> P <br /> m <br /> C <br /> $ a M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- yy�� m u' O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 25 ro <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 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 [ <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g m0 <br /> N <br /> SIGN HERE <br /> (signatufs of owher o 'Idin ra �,'I C� '5 <br /> r— <br /> ZONING ADMINISTRATOR <br /> OCT 1991 o��wwT <br /> TOWN IP PERMITS MAY BE REQUIRED 2 a o o $ m <br /> � 888 (MA <br /> Iv <br /> I <br />