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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3. <br /> ° <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � m <br /> tR <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 2Z Cc <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. y <br /> r c> <br /> O <br /> OWNER (Please Print) Contractor or uve or or Agent m <br /> /2S� Sun <br /> tT te`II�� E � <br /> Address Ad ess <br /> Sl reutw3Mrt 5trzt 4..<<, ._ G sib io <br /> City, State, Zip Code City, State, Zip ode <br /> 8(.4 710'& <br /> Telephone Telephone <br /> la 12- ^7v L-9 Sfo T.qr_`' cy az—s-s0'3 - <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n L7 <br /> ° <br /> Permit(s) Applied for: 0 ,`-- <br /> Dwelling Addition Filling/Grading Camping Unit ° S <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage p <br /> Structure Use:471 0`" D-L- o gig, - gl Qe-A &A&' o <br /> (family home/cabin, gars e, addition, etc.) <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 m <br /> 10 <br /> 3. Show the location of any lake or flowage- if within 10ft. and the location of any river or stream-if within Z `v <br /> 300 ft. ° n <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m � H <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 <br /> dated by the owner. m Q� <br /> PLOT PLAN <br /> H <br /> PF ioxilNeek sAww avl'-5 <br /> m MCA of u, <br /> Ke <br /> y` E04 I o <br /> ,amu` f Rc ft l.«A.D = <br /> 14 t ervra,t N <br /> nx ° (� <br /> PEW <br /> 1 Sa <br /> ' �. <br /> y <br /> NJ S <br /> m o C c�c m m A O.T m <br /> 00 0.OD <br /> N m <br /> C <br /> g <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion 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. 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 u, o <br /> access to the above scribed premis s at any reasonable time for the purpose of inspection. m 8 m <br /> m v AA m <br /> m N V <br /> `I HERE ` <br /> (s' nature owner or b ' ontractor) ata �i <br /> • ADMINISTRATOR -•""' i 'i g ' <br /> J' 19 <br /> TOWNSHIP PERM[ S MAY BE REOUIRED i�i, N a o o S n <br /> ll_it�(-- ��� 888888u <br />