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I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; 'D -i0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 12N 0 (}� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the �- <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. <br /> N d <br /> , iIWRLES V- T5R8E1.LC /(`]AGN/Son/ S<d ( o <br /> ZOWNER (Please Print) Contractor or Surveyor or Agent o <br /> y 7a,� Ait/cHoR INN /4D. <br /> Address Address 1 <br /> u0FRst,C- R W 51Vyy -3 � <br /> City, State, Zip Code <br /> as City,State,Zip Code <br /> Telew- y <br /> Telephone �. <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) ;3 y. /-,, o S. O a y©O <br /> 0s-3S'A/ - - V-ooa Aehes m <br /> Permit(s)Applied for: LsYC S rn ✓ P 203 0` 0 <br /> t1N GeV <br /> r <br /> Dwelling Additions, Filling/Grading - Camping Unit o ° <br /> c�ese i� G rZ � <br /> Accessory Building CAM.AA.9__ Sanitary Privy o <br /> Subdivision ;1Garage U_ <br /> Structure Use: a-�,.t.Ey . _ Acwjf"` "' A: <br /> 0 <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). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). C 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 p N <br /> 300 ft. 11 Z r <br /> 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 O <br /> to lake, river or stream, if applicable. m o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 <br /> dated by the owner. m <br /> PLOT PLAN (j <br /> C <br /> �, <br /> N <br /> m <br /> N <br /> O <br /> Z <br /> x <br /> Mo o c 0 m D a : M <br /> G N N O J a <br /> Z N o N ,2 1 <br /> F m N M <br /> 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 /> 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- .n m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I I i g 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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have c, <br /> access to the above described premises at any reasonable time for the purpose of inspection. a a0 g ° <br /> m 3 <br /> D M N <br /> SIGN HERE �� - ✓ �� w: g <br /> (s' n uref ow r building contractor) (date) <br /> ZONING ADMINISTRATOR C'�l g <br /> TOWNSHIP PERMITS MAY BE REQUIRED C N N O N N �� m <br /> U t N N N N O O O m <br /> ggggggggN <br />