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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o 0 <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 6 o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the I `m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a _Q_ <br /> - <br /> regulations of the State of Wisconsin. y m <br /> -Rc�g(z1 .Brennan Marv— krr7-uSe� <br /> OWNER Plea a Print) Contractor or rveyor or Anent o <br /> armel St. �. (�. �u �� <br /> Address Addres <br /> 6horP,);eu), MPJSSIa(o 1/)P,j)4r?,r ((y— 5k�3 <br /> City, State,Zip Code city,State, p Codd (� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> n L7 <br /> Permit(s) Applied for: o (() <br /> N <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> a <br /> Accessory Building Sanitary Privy o Subdivision a <br /> m <br /> Garage <br /> Structure Use: <br /> r <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M <br /> 2. Show the location of the well (NI),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 <br /> 300 ft. z Q <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 <br /> to lake, river or stream, if applicable. 111 0 <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. H <br /> m <br /> PLOT PLAN <br /> In <br /> 0 <br /> i� <br /> o �o <br /> m <br /> � Z <br /> o c w m o n F m <br /> < m o <br /> Z <br /> fO 1 <br /> o f = ' Tmi In <br /> - In <br /> N moo : O <br /> g nE C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know[- o '^ 0 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 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. 8 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 premises at any reasonable time for the purpose of inspection. n g v <br /> m i 30 <br /> N A N <br /> SIGN HERE <br /> a <br /> (sig2�'tXe of owner or building contractor) (date) <br /> rte'_ <br /> ZONING ADMINISTRATOR \��-`rl Ir5 P. r1i Il r"l 8 S <br /> TOWNSHIP PERMITS MAY BE REQUIRED fit T <br /> fnrnfn u, oo m <br /> 888888880 <br />