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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d0 0 <br /> :APPLICATION FOR — LAND USE — PERMITS 5 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m ' 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 a <br /> regulations of the State of Wisconsin. H o <br /> OWN E (Please Prin[1tContractor or Surveyor or Agent o 1 <br /> �37IoG �f'I/K L6y yIt � f <br /> Addr ss Address <br /> L/t c.:5✓/[.cam �� 5 33'7 �. <br /> City, State, Zip Code City, State,Zip Code t <br /> W2 Di <br /> Telephone Telephone <br /> 297406' 4h"udacsk/ ico <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) I Sror-Y 20 14- o <br /> So%.IT38 /5 0 0 <br /> Permit(s) Applied for: S'c'ere.- 1A- Fx/371�4 _00ct <br /> L o 2 C S— V z 'o L0 m r <br /> Dwelling Addition ✓ Filling/Grading Camping Unit <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage / / <br /> Structure Use: I Cors%�� S C eEex Z'" "AVS'7/w-%r "hlc+- <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 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (OF). ° <br /> 3. Show the location of any lake or flowage-if within 110001t. and the location of any river or stream-If withinMill <br /> 'P in <br /> 300 ft. ° 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 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 <br /> dated by the owner. 4 <br /> PLOT PLAN 3 <br /> m <br /> 1 <br /> \KE o <br /> 0 <br /> m <br /> o � <br /> 75. n <br /> 83 <br /> C�a�✓ da �. <br /> SOro :E <br /> SYS7M' <br /> m o c m m n <br /> m <br /> mC �° o� 3 <br /> Z <br /> M <br /> w m <br /> ID <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my fo <br /> X1 <br /> wl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- " .n m yr [ 0 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ o P [ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- w <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have ro8 0 <br /> access to the abo esc bed premises a any reasons time for the purpose of inspection. m ^ 01 <br /> N <br /> D 3 A <br /> SIGN HERE (sfignatu o - i1 g contractor) a <br /> ZONING ADMINISTRATOR TOWNMITS MAY 2 <br /> HIPSPERMAY 3 O <br /> E(O <br /> R dO' <br /> 1 <br /> m <br /> ssssssssTy <br /> 4k i�c-cif <br />