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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m -o --I z <br /> m m o 0 <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 m (JI <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 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. y a <br /> 7�nEs W0(ZAS f- S/HE <br /> a o <br /> OWNER (Please Print) Contractor or Surveyor or Agent f <br /> �aa� 1�1, 1 s0A 4eve &D <br /> AdessAddress <br /> F <br /> O S4 ,M..vN S5 jQ.� +p <br /> City,SState, Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> �9a 73 to//V E El <br /> Legal Description (as Indicated on tax statement) PC<:<r 00 14, o <br /> zZs, o33oa � <br /> Permit(s) Applied for: 7 J3`k Z— o »- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> Z <br /> v <br /> Accessory Building � Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: L97V7�?TVe <br /> r <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). 0 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 -h o u, <br /> 300 ft. z `o- <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 v <br /> to lake, river or stream, if applicable. m 0J <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. 0 <br /> m <br /> PLOT PLAN / '1 <br /> f nIc �Np Il L-A NE <br /> Ji <br /> Ca <br /> o� sr <br /> l o <br /> . / N <br /> O <br /> 3$ m <br /> o <br /> 5, N C� C) <br /> 6 0' EQ <br /> Z <br /> 41 <br /> F <br /> 1 <br /> o c 2 m w o a g m <br /> a 'n N S <br /> o ro 3 <br /> zmo Az : � <br /> =r M <br /> LR K! po ' --� <br /> �I 8 [ c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- O: o 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- m <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 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- <br /> plication.I agree to permit county officials charged with administering county Ordinances or other authorized person to have N <br /> access to the ab ascribed premises at any reasonable time for the purpose of inspection. m ; g <br /> m 3 n <br /> SIGN HERE �"y ! I ` � ' w Fn ^ <br /> (signature owner or b 'Iding contractor) 1 (date) ,) E <br /> ZONING ADMINISTRATOR �v/��"1 riles+�"�✓t.� o. H(Eq E E E <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> m <br /> gg88888gN <br />