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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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. m <br /> R05FFrr D,OL560 <br /> a <br /> f <br /> OWNERPlease Print) Contractor or Surveyor or Agent o <br /> .3b 3 .OlQ-DAN GIKcLc �. <br /> Address Address <br /> MW EkPbLI S, r/1 N <br /> City, State,Zip Code City,State,Zip Code <br /> 61z,-6YY-)lb5"2-.dv54la 5N95 UA <br /> TeleW &3$_ Sf5) 9 M`kE'Nzl F-. Telephone , <br /> Emergency/Fire No. and Road Name I )/1-�- pP,)V a FIRE NO. <br /> Legal Description (as indicated on tax statement) Lo-r-4). SECTICA)7_Po/ TOWNSHIP 41 NOP-rH m <br /> Rf1✓GE /_5,WIF57' <br /> o 0 V <br /> Permit(s) Applied for: o` <br /> o <br /> Dwelling Addition Filling/Grading Camping Unit � <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o � <br /> Garage <br /> Structure Use: 5GpEEAf ,PORCH (SEA50NAL) o <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 1/ <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). G 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 o c <br /> 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 S <br /> to lake, river or stream, if applicable. M <br /> L. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. m <br /> PLOT PLAN — — '— — '— — ROAD <br /> 49r S <br /> J <br /> o <br /> r NF3 21' 613 52-I N <br /> _ �. <br /> Ib 5 RGH NB i41 m Jj <br /> (SRASO NAI <br /> DF 2 I� <br /> `�' O 0 <br /> unZ <br /> Iqo' — N—► <br /> /� qd��-,.o,,, •tom be u-f�e�s t 5�t- <br /> Tp 10/-,9-, o c m a F T <br /> ° m <br /> a na'� mam a - 31 <br /> Ems : _Q -1 <br /> 131GMCKENZrELAK� 150 N: a <br /> m <br /> m c C <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> PP ( 9 Y ) Y Y 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- [ w ro <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 8 m 8 <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- i <br /> N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have o, <br /> access to the above ascribed premises at any reasonable time for the purpose of inspection'. ' m 8 <br /> ^ N <br /> A <br /> �^/ <br /> SIGN HERE <br /> /r <br /> (si upri of owner ob�µlding contractor) <br /> "ENING ADMINISTRATOR ? -- r -rr� i E <br /> NIN� W(NM � <br /> o o 8 m <br /> TOWNSHIP PERMITS MAY BE REOUIRE�� <br /> 88888888N <br />