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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. — <br /> ° �1 <br /> 70 THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in acco uirements of the m C <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicabl ounty Ordinances an laws and 3. a O <br /> regulations of the State of Wisconsin. 6 ,�, <br /> G�H�IZ 4 eJ f/, hAl p e_RSOM y <br /> n � � O <br /> OWN76ER (8Please Print) Contractor or S rvey Agent o £, <br /> "7 <br /> Address r AddressC� <br /> p4IVXuRy w, _yf_?V °9 <br /> City, State,Zip Cod City, State,Zip ode <br /> 'lis- Y,66- -�/o :Z <br /> Telephone Telephone <br /> Emerge cy/Fire No. and Road Name <br /> 1.OT C6AP, v i 1 P / 07 6N :5w A/w StC re f7OT3 X S <br /> Legal Description (as Indicated on tax statement) Vl L L/f 6 C eF YCLIOW L.4K o <br /> n C) <br /> Permit(s)Applied for: �( o �- <br /> Dwelling ` Addition Filling/Grading Camping Unit o = <br /> v r <br /> Accessory Building Sanitary Privy o Subdivision — <br /> Garage 3 <br /> Structure Use: _- FAM l L Y /fd M ele l9-1 /V 5 <br /> (family home/cabin, garage, addition, etc.) CIO — <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). 21 0 <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 on m <br /> 300 ft. z 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 <br /> to lake, river or stream, if applicable. <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 <br /> Aln <br /> PLOT PLAN /` T <br /> 710 <br /> U <br /> S � C <br /> 3a Ff <br /> .� <br /> Izf- <br /> hof ?S� �Fu1;4 J o <br /> �T_ <br /> AOIT <br /> ( (f` d <br /> N C <br /> 3F ' I I <br /> n <br /> SS ro <br /> o c 0 m D 0- m <br /> eV 5F 00 no 0 <br /> M <br /> �• rt r� G7�0.1LDIAI O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> 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- In m d+ O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ma <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 N 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have O r„ o <br /> access to the above described premises at an reasonable time for the purpose of inspection. m : 3 8 0 <br /> A H <br /> 0,144,— qA <br /> g ! <br /> SIGN HERE d+ '" <br /> (at at of owner uilding contractor) Lr ) <br /> L�"Cu .� _— o : . <br /> ZONING ADMINISTRATOR �g� g <br /> TOWNSHIP PERMITS MAY B UIRE6 ( 5 N N . N N O . O <br />