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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ^ m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0 <br /> regulations of the State of Wisconsin. <br /> DA nn Es is pEr� a V E <br /> OWNE�R.SPleasePrint) Contractor orSuy r�o(Ac)ant _ <br /> �JJI; ES N . &cK - FF = 0 <br /> Address Address r <br /> C�$8 fFAA/SL ) L AIfE AlLWl4'� <br /> Cit State, Zip Code City, State, Zip Code <br /> TlC5ry30 <br /> Telephone Telephone r <br /> 1252 312 P <br /> Emergency/Fire No. and Road Namkl,- ,,- 2OA 0 <br /> Legal Description (as indicated on tax statement) -' <br /> 0 <br /> 0 <br /> Permit(s) Applied for: y <br /> r <br /> 0 <br /> Dwelling Addition X _ Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage ` <br /> Structure Use GHK Po(zt' 33(, <br /> >? s <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). i? <br /> 2. Show the location of the well (VI),septic tank (ST), and drainfield (DF). a a m <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-If within o z `v <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 o <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 <br /> dated by the owner. m <br /> PLOT PLAN _ h{y <br /> -Or O I \ 1 <br /> [� sT <br /> lot '7a w <br /> So' TO ri <br /> CFIRPoat y -_ <br /> -VSO TO L INC ? <br /> m <br /> O y <br /> 0 <br /> !lll1CA9E RD, m o= m m a g m <br /> m <br /> �K% nm ZJ <br /> ZH o pro= 3 <br /> z m " i ZQ 1 <br /> P fes : T m M <br /> In <br /> [ G) c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- E o ' t,. 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 /> chedule)and I further declare that I recognize that this init. I E 9tion contained in this application(including any accompanying sm <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. $ $ <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- w 1 <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have w N m <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> l4— Il- 90 N A <br /> SIGN HERE (date) <br /> (si lure of own building contractor) <br /> ZONING ADMIN TRA <br /> TOR ` - <br /> �NN oo8m <br /> TOWNSHIP P MITS MAY BE REQUIRED $8 8 $ 8 8$ 8 y <br />