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C`r l 00'ii�_ <br /> Burnell.County 741Q Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w Mo 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and �2 y �le�pl <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the �, D- <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 m <br /> regulations of the State of Wisconsin. y ,� <br /> `REDFRICK Pt) EP SELF a o 0 <br /> OWN '(PleLsg, )_��tjT fl� Contractor or Surveyor or Agent Z <br /> Address 111�� �I``�� <br /> ST. PROL Address M4 SSIOS <br /> City, State, Zip Code City, State, Zip Code 1 p <br /> CA <br /> Telephone Telephone 7m <br /> 2 LQ2Z- LRKFV ikI Rb. r <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> m <br /> Permit(s)Applied for: o ° �t <br /> m r fT- <br /> Dwelling Addition Filling/Grading Camping Unit E °^ F <br /> ` / Z o 7 <br /> Accessory Building Sanitary V Privy Subdivision P m <br /> Garage <br /> 'ib� J�Yli�lhzyjolcl, 7io>ti Ut <br /> Structure Use: U.i cL <br /> (family home/cabin, garage, addition, etd) O <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). <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 Fcn <br /> 300 ft. o $ <br /> 4. Shaw dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c) building n ► v, <br /> to lake, river or stream, if applicable. m 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. m O <br /> PLOT PLAN C i7 Li� G � <br /> E S 6 91 <br /> O � <br /> 0 <br /> IN <br /> � <br /> Q <br /> Z <br /> �- <br /> r <br /> e <br /> n7 <br /> 00 <br /> 0 _. <br /> m . <br /> =' m <br /> � [ G) O <br /> I declare that this applicatio4.(including any accompanying schedule)has been examined by me and to the best of my knowl- 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 m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- b" 'm vim, <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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 0 o, v <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> SIGN HERE ` t �- d'H 8 <br /> signature o ner or building contractor) (date) o <br /> ZONING ADMINISTRATO 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED v N o 8 8 m <br /> 8888888M <br />