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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'Do l0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m 0 <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 M c <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and _ n <br /> regulations of the St to of Wisconsin. <br /> Rn <br /> K 4,00 <br /> H m <br /> �.(�t 11 tam �. tlLllrclW[� 1 nCA 400kIk"S 0 O <br /> f <br /> OWNER (Plea a Print) Contraptor orp�sury yor rAgent o <br /> 1 a0 L 0 t�uceil i4ue W 2b6r <br /> Add settAddress <br /> L4 JQ ►- Lot <br /> ,s 5 W90 <br /> City, State,rZip Code City,State,Zip Code O <br /> 1 <br /> Telephone Telephone _ <br /> P <br /> Emergr=, re N and Road 5eNim�O TL/oN RN 0 <br /> Legal Description (as Indicated on tax statement) <br /> A L) <br /> Permit(s) Applied for: , 0 o <br /> y O <br /> Dwelling Addition X Filling/Grading Camping Unit <br /> v <br /> Z o 1 <br /> Accessory Building Sanitary Privy Subdivision 0 m <br /> Garage <br /> f^� �n - �G16 <br /> Structure Use: > o <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). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 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 on <br /> ? c <br /> 300 ft. 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 N <br /> to lake, river or stream, if applicable. <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. <br /> 111 <br /> PLOT PLAN ,{ � <br /> yea <br /> �U �� 7 iG `�v lcS ��✓�� �U� ��V O <br /> wetly rS est Mkfiaadwe+I� <br /> LS 0_ti LSo Icfaf� W�tI � toocicc f , <br /> Nr� o <br /> o <br /> • QN r\ Fel'It'„`� �pl` tney Cllr - L(pKcac�,Ia�ICr� m o c m a E m <br /> • CJ V o_ aii� maN am M <br /> P '�P- o,.. l I—13-90 �-/4cI rcktt� < N. = e C g ,0 3 <br /> f • QYu.�� /t/e'�5ow l.F1r� � �^ ��.w 3 VI e1.,2Gd 5� <br /> �(/ • : € m <br /> I p k Crm <br /> Pe°�a Wood �-a,l( LIN. 16r rn �(/u-14ow 4>,de Perrnaf ��fi� <br /> II�� g . a • E <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- �ry, m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa. <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 <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 o <br /> access to the above described premises at Ry reasonable time for the purpose of inspection. w 8 n i <br /> m V A m <br /> SIGN HERE <br /> si a of owner b 'ding contractor) (date) <br /> a . x : <br /> ZONING ADMINISTRATOR "N. g <br /> (p(H bI�HfFHf{q� T <br /> TOWNSHIP PE ITS MAY BE REQUIRED N N Nl N N 8 8 O m <br /> $ 8888888ai <br />