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0Y-I Q r"If \ . <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m T o r o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and q � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the q <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. o <br /> R <br /> Chace /l 90 49'n r/ C' ro iLS a O <br /> OWNER (Please Print) Contractor or Surveyor o¢Agent o <br /> // 2S Hr.l/ren Sed X79 r12 �t �y L�n1 m <br /> Atltlres { / �- Address / g <br /> ?O 4r - /3 e.•,<i 1 <br /> City, State, Zip Code City, State,Zip Code <br /> .2/ 9.5 <br /> 259- 93P3 - a2S9 -33y6 9J a <br /> Telephone Telephone <br /> Emergency Fire/No.�'ari�d Road ryaQ_e <br /> Emergency <br /> K[r�nf l- tri Dai <br /> Legal Description (as incilcated on tax state ent) o <br /> Permit(s)Applied for: o <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision P 0 <br /> Garage a <br /> Structure Use: �t�d u ec X. l H Y'z) <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: Q <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DIF). Q 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 <br /> 44 9 m <br /> 300 ft. 11 Z c <br /> o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building Q <br /> to lake, river or stream, if applicable. 111 o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. M <br /> m <br /> PLOT PLAN <br /> 1 <br /> 30 <br /> I <br /> 0 <br /> � o <br /> �h <br /> �f. <br /> w x'04 <br /> J 4 'of mgo T .0 py <br /> � a <br /> M <br /> a <br /> am <br /> f ZZ0Dm3 <br /> k,e , P � � r(D y <br /> g m <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m <br /> Ptto : O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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 g <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 ro ' <br /> access to the above described premises at any reasonable time for the purpose of inspection. ro u,m <br /> m 3 $n <br /> A <br /> �S Via- qi AA % <br /> SIGN HERE Z � � R <br /> (signatur of owner or building contractor) (date) o <br /> ZONING ADMINISTRATOR ')t. <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> fnmrnrnoo $ m <br />