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O C y�' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -00 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w v t <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the LYA <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> LePaa� M <br /> CL <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> �{C1110 Nair; ej Ave. S. <br /> Apdress 5 U Address <br /> I Y\City,'State, City, State, Zip Code 1 <br /> I-krn� l.�(a��� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s) Applied for: o <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit 0 °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P m <br /> Garage <br /> Structure Use: r.AV`AlG P r <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). 21 n <br /> 2. Show the location of the well (W),septic tank (ST), and grainfield (DF). e 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 p c <br /> 300 ft. milla 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 N <br /> to lake, river or stream, if applicable. m <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 <br /> dated by the owner. 1A <br /> PLOT PLAN <br /> I <br /> � 1 <br /> 1 U) <br /> 0 <br /> 0 <br /> o � <br /> m' <br /> PLOT PL✓JN ATT/9�N <br /> Iff. <br /> I <br /> o c M . m o a m <br /> < ` 2vc, oMro 3 <br /> P f ; m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- n ? [ 75 m E <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 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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have o, I <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m 3 n <br /> y e <br /> • m m <br /> SIGN HERE <br /> (si of owner orob ding contr tort (date) o p ! [ <br /> ZONING ADMINISTR [ 8 € <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> N N N N N O O m <br /> ggggggggN <br />