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Dry c <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and N <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. ) �, m <br /> LR(yC/s �, CJ5LSK/ LAI4g CONy7-RuCTt'0C) m v o <br /> OWNER (Please Print)Se� Contract or Surveyo or Agent o <br /> /l03 ! U!r l <br /> Address / Addresb <br /> TGy,�7 t <br /> - - � m <br /> Ay/ A) 5sle C� RAv-rs 3VR(. fSc,�,�s'r.J <br /> City, State, Zip Code City, State,Zip Code <br /> /-- — <br /> Telephone Telephcy2 <br /> Emergency/Fire No. a9gd Road Nine p <br /> �i0T (.� �1 Z1NP-1s e / BINS' tic> <br /> Legal Description (as indicated on tax statement) g �. <br /> Permit(s) Applied for: o ° <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage /� p <br /> Structure Use: f r,44 A G" e 'lL J 70A AX T- r <br /> (family home/cabin, garage, addition, etc.) o <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 n <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 ur <br /> 300 ft. Z <br /> 4. Show dimensions in I eet of the I ollowing:(a) building to all lot lines,(b)building to center line of road,(c) building 00 a <br /> to lake, river or stream, if applicable. M a <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 /> PLOT PLAN <br /> ('Z CAbIA) . <br /> �q0 <br /> Q <br /> o <br /> —o C Z <br /> 14( <br /> Q AUG 2 21990 <br /> DD O <br /> o c ry a F m <br /> M <br /> 22. : C <br /> Oo z m. : o o <br /> \ P F E T y i M <br /> UAI !(ISE 40 % E _ o <br /> $ m c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- (n G) <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- `b' <br /> mation I am providing will be relied upon by the Count of Burnett Wisconsin in determining whether to issue a permit. 1 m <br /> P 9 Y 9 P $ <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 ty officials charged with administering county ordinances or other authorized person to have c„o <br /> access to the above de ribed remises ny re able time for the purpose of inspection. w <br /> m 3 <br /> tD f V � H _ <br /> m � a <br /> N $ <br /> SIGN HERE <br /> (si 1,,e of ow building contractor) Z ( ate) <br /> ZONING ADMINISTRATOR g . <br /> d1 fA (A fA di d1 In <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> N (li N N O O <br /> $ $ 8 $ $ $ $ $ N <br />