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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'u o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m 0 <br /> TO THF ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and io <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <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. If <br /> H <br /> �IiYJYi�-�S l� • 0AC— a fio <br /> 0 N R (Please Pri t) Contractor or Surveyor or Agent o <br /> Adess �A. <br /> Ad ess Address <br /> i100,eapld AI ��ILrR <br /> City, State, Zip Code City,State, Zip Code I <br /> 3.6- 7Ze I <br /> Telephone Telephone 3 <br /> Emergency/Fire No. and Road Name ( ' <br /> Legal Description (as indicated on tax statement) o <br /> n L7 <br /> Permit(s) Applied for. o ° <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o m <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage (� A n,r,/ <br /> Structure Use: CA ( )`-� /D r X o20 � �.4$P/AJG iYff��I <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: G <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). C) 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 m <br /> 300 ft. ` <br /> Z c <br /> o c <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building Iz <br /> to lake, river or stream, if applicable. Ifl j <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C l <br /> dated by the owner. M <br /> PLOT PLAN / v <br /> Le O 1 <br /> N111, Cn <br /> E130 <br /> 3-�� m <br /> KJ <br /> n <br /> z <br /> V � U <br /> m o c m io o ag rrh <br /> n <br /> m. Da� � o. N ami <br /> o < Q <br /> "o cm 3 <br /> f v i <br /> M ( M <br /> _. m <br /> G) <br /> 8 <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informa- <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 8 t <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 ,,, <br /> O ' Vi <br /> access to the above described emises at any reasonable time for the purpose of inspection. m 3 8 0 . <br /> n : <br /> V A x <br /> SIGN HERE 50 w Fnm <br /> (sig ar of oViner or building contractor) (date) [ <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED $ o o m <br /> 88888888vm, <br />