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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ' o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3, <br /> TO THE ZONINO'ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and is 0 <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. IIYYYVJJnnn��l <br /> regulations of the State of Wisconsin. <br /> N d <br /> cin iV %SIC/i4 �fk�J1, 1I Tll7't G✓,s«iiFk- GyGvgT, 0 ' o <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> ,�u�, N JET gr x yt ° <br /> Addr ss Address g <br /> IVA1DGL( Ef IMA/, SSSyZ <br /> City,%a!6,Zip Code City, State,Zip Code I <br /> WG 3s L2, <br /> Tele honTelephone <br /> ��)ne ���-Q — 3'5,'9 —s1/73 z <br /> Emergency/Fire No. and Road Name -� <br /> Legal Description (as indicated on tax statement) o �J <br /> 0 <br /> Permit0 <br /> Permit(s)Applied for: o <br /> Dwelling Addition X Filling/Grading Camping Unit 0 � <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage (� <br /> Structure Use: G�✓�� Y ; r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <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). X O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 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. an Z a <br /> o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building A <br /> to lake, river or stream, if applicable. M <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 ,� <br /> �) 73 Z <br /> PLOT PLAN <br /> I <br /> i m <br /> 0 <br /> 0 <br /> o <br /> IP <br /> Z <br /> oc TmmnnFm <br /> � a.� '-'o- N » 2. M <br /> a m < 01cmo = 3 <br /> Z mo ' ? mZ ' `° 1 <br /> P f o [ r0i M <br /> to i G) p <br /> 8 i mom : c <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 /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe detail and accuracy of all informs- vs m O <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 g m <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 /> 000 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m : 3 8 m . <br /> n <br /> o ' E vA m E <br /> SIGN HER < U — l to m g <br /> E <br /> (signature of owner or building contractor) (date) <br /> �1 g1lJ) 6f}ri�TRATOR o <br /> ZONING ADM <br /> TOWNSHIP PERMITS MAY BE REQUIREDN N 8 0 a o 9 m <br /> $ 888 $ 889um) <br />