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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator m - o a <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> 0 <br /> TO-THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> Ln <br /> 'o D <br /> lc/ILL /AA7 OAlA21I L,4m6k Lw%78, L – Seo;yf e <br /> OWNER Please Print °- F <br /> ( ) Contractor or Surveyor or Agent = <br /> o <br /> Address Address " I <br /> DF�NQulL�� fit✓(. 54 3; -' oPpv <br /> City,State,Zip Code City,State,Zip Code <br /> 7/S-zs 9- 74 zit <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o (� <br /> n <br /> Sanitary Camping Unit o O <br /> 0 <br /> Privy SubdivisionO <br /> 0 <br /> / r " r <br /> Structure Use: FA L H{ 1 f– t rbk- TL-, ;Dwell, <br /> (family home/cabin, garage,addition,etc.) o 'o <br /> m <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). <br /> 2. Show the location of the well (W), septic tank(ST),and drainfield(DF). <br /> 3. Show the location of any lake or flowage-if within 1000 ft.and the location of any river or stream- if within 300 ft. o <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, S <br /> 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 dated by <br /> the owner. 6. Provide legal land description. <br /> PLOT PLAN tf 4 -S 1B cw G-eEr�t.Q%ei+-. ��t•S�GI ,G�2c.L 3 <br /> 7T j^ G O p to <br /> Z a <br /> A r i y: <br /> d an <br /> k!1 icg R1 t�• w <br /> OQ 8 m <br /> See Pert,,ttt� I? o <br /> SAA), <br /> tow !Lr- <br /> !b u'• 0 m <br /> ✓�I -- A16W <br /> tGZ 4 <br /> aDpf77r,✓ o <br /> L>yo� <br /> yoR4wF� / i.Zy ! <br /> (OM— <br /> m c-m w o a a m <br /> 12 69cm <br /> .Ts 1,4 fb L l Z 0 o � <br /> o id 0 0, <br /> [ o)ZZ : s <br /> 2 m <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m o c C <br /> PP ( 9 Y 1 Y Y p: i i io y <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all r 11 A m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> fy1� � m <br /> SIGN HERE r!— 7–S–g !4 <br /> (si 9/rWTre of owner Iding contractor) (date) i rd'„ <br /> o: o <br /> ZONING ADMINISTRATOR a <br /> i i i 0-n <br /> TOWNPER TS MAY BE REQUIRED . p c pm <br /> N<nQv m <br /> coca rn <br />