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Burnett County 2410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w - -0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. 0 s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ^ io <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and a <br /> 'o <br /> regulations of the State of Wisconsin. y °: <br /> c <br /> 0 O <br /> Lay r,r L 'y' n f <br /> OWNER (PI ase Print) Contractor or Surveyor or Agent o m <br /> 7�9w� �Aa� A.at•-�.� Qd <br /> Address /� Address t <br /> City, State,Zip Code City,State,Zip Code <br /> I�1 93 '7 - A5-1// —� <br /> lepho a Telephone i <br /> Emergency/Fire No. and Road Name <br /> T <br /> Legal Description (as Indicated on tax statement) <br /> n_ 00 <br /> Permit(s)Applied for: o <br /> 0 � <br /> o' <br /> Dwelling — Addition Filling/Grading Camping Unit T <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: Cw6 h RYIf ] �� JS7Fil� = <br /> (family home/cabin/garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O O <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield 1 c <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream-if within 11 p in <br /> 300 ft. z o <br /> O c I <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 o <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 C <br /> dated by the owner. M <br /> PLOT PLAN <br /> - ' m <br /> ll� 0 <br /> a <br /> �w 0 <br /> W4 <br /> A <br /> z <br /> I <br /> e f <br /> _ A <br /> m o � �° mm �agIn <br /> ee �TL� m <br /> 1 Yerf+� o 1 50..2 00. 2 3 <br /> 0 2: ; C 0 0 5 <br /> < � : � o � m � <br /> $ E ? n E <br /> 71 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o E 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 0 H? O <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- E ism <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a permit. 1 8 0 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have O c„ O <br /> ,ccess to the above described premises at any reasonable time for the purpose of inspection. 0 8 0 <br /> m i 3 0 <br /> m V A m <br /> H8 ? <br /> 'ERE (date) <br /> a : <br /> (signature of own r_or b 'Iding c t x <br /> 30-471 <br /> AINISTRATOR ' <br /> � nMo�ww <br /> T4/1 <br /> O NSHIP PERMITS MAY BE REQUIRED N N P N O <br /> 88888 <br />