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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> m o <br /> TO THE 20NING 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 OK i7-? <br /> regulations of the State of Wisconsin. y m <br /> f1u,2/ei2c5 oA/ MOALT/7/11-,o .131,LQC t s �w� a = . <br /> ,o <br /> f <br /> OWNER Please Print) Contractor orSurveyPf�rorAgent <br /> Yee <br /> o (s <br /> Address �d1ress _ kr� <br /> -ST f�,4 U L /n;17n 5_S!2 (y .Vi+ir1.1I- 5--744F,30 t'J <br /> City�l.2, State, Zip Code City, State, Zip e �f <br /> �- <br /> Telepho e Telephone _ <br /> �f+i:YC.S ZklyC <br /> Emergency/ re No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: o rl) <br /> it <br /> Dwelling Addition Filling/Grading� Camping Unit <br /> Z B <br /> T <br /> Accessory Building Sanitary Privy Subdivision P $ <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: J <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). n <br /> 2. Show the location of the well (MI),septic tank (ST), and drainfield (DF). 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 <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 0 y <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 <br /> dated by the owner. m �:1 (� < <br /> PLOT PLAN <br /> C <br /> 8H' ( 0) <br /> f;bprj'E� o� <br /> -- _ <br /> cm ; <br /> jcIL-cc,) <br /> r6 mzt�- <br /> J, D to tnvulr DD � <br /> m a g m <br /> . ? o mem <br /> 3��f � Via ' zHo �m3 <br /> c � <br /> M <br /> Z L N D <br /> I declare that this application(including any accompanying schedule)has been exami ed by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible f the detail and accuracy of all fnforma- w m o <br /> tion contained in this application(including any accompanying schedule)and I furthe declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in d ermining whether to issue a permit. I ? 8 m g <br /> further accept all liability which may be a result of the County of Burnett relying on th s information I am providing in this ap- <br /> plication.1 agree to permit county officials charged with administering county ordinar(ces or other authorized person to have <br /> access to the ab described premise t any asonable time for the purpose of inspection. m g m <br /> m 3 m <br /> ? A e` <br /> u+ N8 : <br /> signature of owner or building contractor) (date) o I x <br /> ZONING ADMINISTRATOR till, )&4A/ <br /> 8 <br /> TOWNSHIP PERMITS MAY BE REOUIR D 8 " <br /> Opi N,.po.pN pO pO <br />