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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - _0 O <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m j <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the W 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. <br /> be v CJD 1 t'ere� �yY l� �Lb GS, n = o <br /> OWNER Please Print) LL Contractor orSurveyororAgent o n <br /> �/t�/ &!It- Cr-cstCT, "7 � /� �� ? /Yic- �a� � pr, m L5 <br /> Address Address -- <br /> �c rw onLocv� �l (SIS 53 �(o (c fav C 1 ,,� � e , UIS S�j7D3 <br /> City, State, Zip Code City, State, Zip Code 1 <br /> ,�zi4 - S (,� 7- 6306 �— <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> 5 � -A /7 /� /S�IiJ r�.)-es 210, UUO P:ZL 30 Y 13 •y2o <br /> Legal Description (as Indicated on tax statement) Yy Lv ry L-- o r <br /> n L7 <br /> Permit(s) Applied for: o °- <br /> Dwelling Addition Filling/Grading Camping Unit S ° <br /> v <br /> Z g S <br /> Accessory Building —4— Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: n U'Cf <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <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 0 <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 11 o <br /> 300 ft. z v <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 5 o N <br /> to lake, river or stream, if applicable. in 5' <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 /> PLOT PLAN — <br /> ��� <br /> 0 <br /> 0 <br /> J Lf <br /> � y <br /> w <br /> Z <br /> Z <br /> r <br /> f <br /> m 0 c m m n V m <br /> m 0a oam <br /> mm M <br /> Z <br /> P eF � [ TN m <br /> = m <br /> C <br /> c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- r� 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 it E O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- v <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described pr mes at time for the purpose of inspection. m m 8 <br /> A a <br /> a <br /> .-r ( ✓ �:il a i m8i <br /> SIGN HERE <br /> (sig ure f owner <br /> � x <br /> ZONING ADMINISTRATOR tib <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8 8 88 <br /> mm <br /> $ $ 8 $ $ 88ai <br />