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uy <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m � oo. <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and rn <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 n <br /> regulations of the State of Wisconsin. H , <br /> / ° <br /> OWNER (Please Print) Contractor or Surveyor or Agent 'v <br /> i/ ) £ <br /> m <br /> )I,Pa70 M4'0„z;0 i?./ /-ltp-sy � <br /> Address Address ! <br /> City, tatebip� City, State, Zip Code <br /> Telepho e Telephone <br /> 3� fs9 aive <br /> b <br /> Emergent /IM o. and goad Name <br /> ThM C�/,,n <br /> O »S' An-4hWvn. �L . � �vi ni !l ran u�/lP Lisle 1,2Iti3RL.t/�- <br /> Legal Description (as indicated on tax statement) o <br /> n O <br /> Permit(s)Applied for: a °- <br /> r' r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> Z <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: — S-4b4;t 4-occe. Sid he. $'/eer iN ;� <br /> (family home/cabin, garage, addition, etc.) <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). M O <br /> 2. Show the location of the well (W),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 o <br /> 300 ft. a n <br /> 4. Show dimensions infeet ofthefollowing:(a) building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. M 3 , <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. 10 O <br /> 1 <br /> PLOT PLAN fQoon ry L. KQAP v.V <br /> 7(j�2 h4 1'116�� <br /> + <br /> N <br /> I � O <br /> 1µ �` <br /> N <br /> Nary <br /> gLJp m <br /> o N � <br /> t � � <br /> t z <br /> ' � D <br /> I <br /> dab+n ) <br /> - -�i�-'-- AO <br /> �}F 10 iS bti <br /> ,yr ofy �,�II F <br /> 1 . <br /> 63 <br /> to 1 °Q � >? Ra 9 <br /> i 1 <br /> a m < m C� Ho oo ,o �— <br /> m <br /> = m <br /> Ro� nay 1-�Ka i� ? o <br /> s <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 4 : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- 0 p <br /> tion contained in this application(including any accompanying schedule)and 1 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 o 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 ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have access to the above c ibed prem" t any reasonable time for the purpose of inspection. . m 8 eo <br /> V n N <br /> SIGN HERE H d+m 8 <br /> (si nature of ow rjKr b 'Iding ractor) (da ) <br /> ZONING ADMINISTRATOR • - g : . <br /> TOW HIP PERMITS MAY BE REQUIRED N a m <br /> 888 $ rmn <br />