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Administrator Z <br /> Adm „ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning 3 <br /> o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 0 - o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 n <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and o <br /> re lations of the State of Wisconsin. <br /> N (p <br /> m r osza < Se a � <br /> Contractor or Surveyor or Agent <br /> O! lease Pnn r h <br /> Ad Address W <br /> Ad o �► �� LOT 5q2-71 I <br /> City,State,Zip Code <br /> City, StateVp Code <br /> Telephone Telephone <br /> f4- <br /> Accessory <br /> 965 A ba LN,Emergency/Fire No. and Road Name OS0CSIYt 1 �l Legal Description (as indicated on tax st tem ) @o <br /> 0Permit(s) Applied for: o <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit v <br /> z Building Sanitary Privy Subdivision o <br /> Garage t <br /> Structure Use: <br /> Ca 30 � Op <br /> (family home/cabin, garage, addition, etc.) � <br /> 0 <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 drainfield (DF). 3 N <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within z a <br /> 01 <br /> 300 It. o <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 I� o I <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 a �1 <br /> dated by the owner. <br /> PLOT PLAN <br /> — 2 0 k g-H 4-4AJ i r4 <br /> C = <br /> y, r <br /> Cn <br /> N I� <br /> o � <br /> .30V 3 5C9DQJ <br /> r n <br /> t � z <br /> 2`I � <br /> Ir <br /> 31� o c V w d oo o. O rn� F m <br /> a N a m a <br /> ,2m00S ,p3 <br /> 0 £ rw : 1 X <br /> rr <br /> C <br /> 0 - 3 <br /> application including an accom an in schedule)has been examined by me and to the best of my knowl- o n <br /> I declare that this app 9 Y p Y 9 p p: <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- e, <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> �: 8 <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 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 0 8 <br /> v <br /> access to the above Ascribed premises at any reasonable time for the purpose of inspection. m 3 g <br /> -90 <br /> SIGN <br /> vA ✓ <br /> SIGN HERE (date) <br /> (signs f ow ILI <br /> er r building co ractor) a.�. p : <br /> h g <br /> ZONING ADMINISTRATOR <br /> N N N N O O o <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />