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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (n ' o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3' <br /> w <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <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. <br /> a v ° <br /> OWNER (Please Conttrntofo-r1�J1/—L�4s_aq/ Agent <br /> Q 0 Lo 'm <br /> Ad�d�gss J / / ' Adds <br /> ( wrc�pt✓ 'c S'VS_gt; rc< y,-./(TSb urek tugUb ( (? <br /> City, State, Zip Code City,State,Zip Code �t s— <br /> �( 2 ;2C <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name U�) <br /> 0 " -;tC c. <br /> Legal Description (as indicated on tax statement) m 'U <br /> o L7 <br /> 0 <br /> Permit(s)Applied for: <br /> '^ r <br /> Dwelling Addition Filling/Grading CamPIgUnit o 0 <br /> v <br /> Z o <br /> Accessory Building — Sanitary Privy Subdivision <br /> Garage <br /> tr <br /> Structure Use: C ^^e o <br /> (family ho a/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). O O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within on Z <br /> ? c <br /> 300 ft. P o <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 m o <br /> to lake, river or stream, if applicable. 04�) 0 � <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C t <br /> dated by the owner. m W S <br /> PLOT PLAN �( <br /> CD <br /> - w <br /> m <br /> SuJ <br /> o <br /> m <br /> C p <br /> D o o 4- �� W <br /> 700 <br /> x <br /> r- <br /> pl (q 17 fN r D D O m <br /> / {UQIti MF2t' �lC(l�1 f- N-�Ig11,1' Ye7 ulaEM C+�13 (.uL LT Iti �p t/d/{47 T. M_. I. aN o. Fid c <br /> III Q �C�il /w,r ISSi.rLt�G2. o ; T� ` M <br /> }}�� ✓F i � i m <br /> C - d6 G✓C ojeec <br /> m c . <br /> M <br /> Id lave that this application(including any accompanying schedule)has been examined b me and to the best of my kno - 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro <br /> mation i am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ $ <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 0u, o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 8t° <br /> A m <br /> N m A <br /> SIGN HERE / ' p <br /> (signature f or buil i contractor) V1 o <br /> s: <br /> PING ADMINISTRATOR <br /> ,Pi, 25 m <br /> WNSHIP PERMITS MAY BE REQUIRED A P,� _ i �� m <br /> �� 88888oo888 <br /> NtH <br />