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Burnett County 740 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o h <br /> TO THE ZONING ADhINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown henin. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Tse Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n C <br /> regulations of the Stae of Wisconsin. rn m <br /> N � <br /> 4OHPSOi✓ � / Y n C) f° <br /> OWNER (Please Prirn) Come or Surveyor or Agent o <br /> 6-0qt7'7 &RAAI/TF ka-F st/H lJ m <br /> Address Address <br /> SG07-7St7A4E A? 95250 }) � <br /> City, State, Zip Code City,State,Zip Code C� <br /> Telephone Telephone <br /> ORos��cr 5'r <br /> Emergency/Fire No. and Road Name <br /> ZI42 S(( - � �_ )5 *1& Zj'id'C-< <br /> Legal Descriptiona6iclotax %8 <br /> statement) <br /> o <br /> Permit(s) Applied for: STA//¢ WAY 0 <br /> Dwelling Addition Filling/Grading Camping Unit c °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage < p <br /> Structure Use: C-A81A] r•- <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). <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 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 /> 300 ft. o n <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building C 4J F cell <br /> to lake, river or stream, if applicable. M o 0 <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. (A C <br /> PLOT PLAN <br /> v i ! <br /> r 3a 0 00 <br /> 93 N - <br /> `; <br /> X <br /> iv <br /> r <br /> aC �✓ z <br /> 11 T N06/SCE Ndyg T � y <br /> ` I <br /> Q A O c m m o n 9 <br /> 0 m. Dn� aN oma <br /> '^ " � m <br /> Viom' 3 <br /> Q 5 2 Q <br /> 8 o i i T y i S <br /> m <br /> 8a <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- �1..) S m In <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- e,a [ O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ 'm <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I E g m g <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the ab described premi reasonable time for the purpose of inspection. m g <br /> m 3 n <br /> D p pA w <br /> N S : <br /> SIGN HERE �^: n <br /> (sig ur f ow r or u' mg contractor) a " <br /> o : P <br /> ZONING ADMINISTRATOR �� ����� <br /> TOWNSHIP PERMITS MAY BE REQUIRED N O 6 m <br /> N N � <br /> R yi ca �a o , .rb' <br /> 888888 gy <br />