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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator rnM z <br /> 0 0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 _ <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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 0. <br /> regulations of the Sttfata of Wisconsin. {n/1�_ Q �(r) <br /> Z �Sa-✓ 11`�I�.S Vla.t lcX,O e-1 c O <br /> OWNER (Please Print) o f <br /> Coryragtor or S e or r Agent o <br /> ( qLo ( g d <br /> Address L i m <br /> 4-,e— GJ. S� $4 f3Addr cwi: <br /> City, State,Z)p Code City,State,Zip Co e <br /> g91LQ -7fo`3 i QJ <br /> Telephone Telephone 1 <br /> 0 <br /> Emergency/Fire No. a�F1 Roatl Name P— <br /> Sc. jt ( 03 D#* 1 <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s) Applied for: o <br /> 0 5 <br /> 0 <br /> Dwelling AdditionH <br /> Filling/Grading Camping Unit o <br /> v <br /> Accessory BuildingSanitary Privy Subdivision <br /> Sanita Pri o <br /> Garage <br /> a <br /> Structure Use: S��vCSe f Kia L-'o 61l< <br /> (family home/cabin, garage, add' n, etc.) I <br /> DIRECTIONS FOR PLOT PLAN DRAWING: Q <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C o <br /> 3. Show the location of any lake or flowage-If within 1000 ft. and the location of any river or stream- if within I ? m <br /> 300 ft. Z c <br /> 4. Show dimensions in feet ofthefollowing:(a) building to all lot lines,(b)buildingto center line of road,(c)building P <br /> to lake, river or stream, if applicable, <br /> m o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. M L <br /> m , <br /> PLOT PLAN <br /> y0 P+ <br /> ca a <br /> J 0 <br /> Ip <br /> O <br /> J 'LNy <br /> IR % <br /> � 1 <br /> v of t z <br /> ` D <br /> 32 <br /> - <br /> 4 - <br /> -- `' m mu vm� <br /> i a0aaR._ 9 <br /> jaSZ '_. Da - 0 <br /> T <br /> 0 o �' 3 <br /> 15 rtjt:. �.+� o f 3 � <br /> / P m <br /> ]<f N 0 C C <br /> 6 5 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S ? tm <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- mtion 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. Ifurther accept all liability which may be a result of the County of Burnett relying on this information I am providingin this ap-plication. I agree to permit county officials charged with administering county ordinances oron to have <br /> access to the above described premises at any reasonable time for the purpose of Inspection. l <br /> SIGN HERE <br /> a <br /> signature ilif ownerr butlding contractor) (date) i <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> cn v, ut ul o o m <br /> 8 $ 888888rmn <br />