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Burnett County 7410 Co. Rd. K, No. 102,•Siren,WI 54872 Office of Zoning Administratoro 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. H d <br /> 1 m <br /> �JI�DI IN 1L • f�e� YOW h�aOttA�ES� cl� "F.Pr" a f <br /> O NER ease Print) or S <br /> -6eRtraeterurveyor Agent 'v <br /> 71J(Pl2430ove�xxz�Tl'v� FPb,$D,x tsar�al�� LJ,Clu1eF►,olNd <br /> A d��ess dres I <br /> kf�1g �i�rr�N�tN G,�,1�'3R I��udte� 1>tl�nnl���) i4�/OZ-Isg� <br /> City, State, Zip Code City,State,Zip Code <br /> 414-- 52���C35510 'I IS 831 - 31b1 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name LIN. <br /> t�nl L�1 i �iD tr 1 J <br /> Legal Description (as Indicated on tax statement) <br /> 0 ct <br /> Permit(s) Applied for: o °_ <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Z o <br /> Accessory Buildin Sanitary Privy Subdivision ° <br /> Garage <br /> StructureUse: <br /> 0 <br /> T (family home/cabin, garage, addition, etc.) � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> &I-1Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). A 0 <br /> tZ.' Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 <br /> X-Show the location of any lake or flowage- if within 100011. and the location of any river or stream- if within <br /> 300 ft. o n <br /> ,*.'Show dimensions in feet of the following;(a)building to all lot lines,(b)building to center line of road,(c)building C w <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 1 <br /> dated by the owner. m <br /> PLOT PLAN C <br /> I <br /> 1. <br /> O 0_ <br /> 0 <br /> O�11 O <br /> .Y I' <br /> 0 <br /> J <br /> 7 <br /> w <br /> `!� Z <br /> OD <br /> o c - 0 m o a g m <br /> a00 am <br /> Zgoo 0. Q' 3 <br /> Z o <br /> P . <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- Qt_ o m '" : 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- <br /> tion contained in this application(in ompanying schedule)and I further declare that I recognize that this infor- U v E m <br /> mation I am providing will be re d upon by the unty of Burnett Wisconsin in determining whether to issue a permit. I g 0 g <br /> further accept all liability whi may be a result o he County of Burnett relying on this information I am providing in this ap- 1. <br /> N <br /> plication. I agree to permit c unty officials ch ed with administering county ordinances or other authorized person to have u, <br /> 0 0 ; <br /> access to the.abov er' ed premi s at y reasonable time for the purpose of inspection. m 3 8 80 <br /> A V N <br /> A N <br /> SIGN HER .;; d' <br /> re f owner it m contractor) r <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDi't,I J� APR 2 5 1991 a m <br /> u �f 88888{, 88rmn <br />