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O)R k <br /> I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) - 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 ie <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m 1 <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 Wi onsin. 1 O <br /> OWN--RY <br /> ( asfl77��•, t) Contractor <br /> a E <br /> oyh�S�urve oyer Agent ; o <br /> = CYJ <br /> 4-0 g� Address , - c T t <br /> City, State, Z <br /> l I Code S o -7 S� City, State, Zip Code ` W <br /> �� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> s' 9 -n <br /> Legal Description (as indicated on tax statement) -0 7 /3- AC RC-5 ,.2 3 O o <br /> 1�gro1y S 104 -oV A.0q P 474 �eA 40 Zro r o3roo0 ��< �vl. Lor � S <br /> Permits Applied for: ^- <br /> o <br /> a,0 A.o r R-V� 0 <br /> /Ye-f,.) R©oP onJ Lcnirs y <br /> Dwelling Addition ling/Grading Camping Unit o <br /> v <br /> Accessory Building Sanitaryz <br /> Garage Pnvy Subdivision ° <br /> Structure Use: <br /> (fki <br /> mlly h me/cabin, garage, addition, etc.) <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). M 0 <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 v u, <br /> 300 ft. Z <br /> 4. Show dimensions in feet ofthefollowing:(a)building to all lot lines,(b)building to center line of road, (c)building o a <br /> to lake, river or stream, if applicable. M N <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. (A i� <br /> m ' = <br /> PLOT PLAN pp <br /> m <br /> AC �1 <br /> P o <br /> ilk40 <br /> sf <br /> m <br /> o � <br /> N <br /> RPPra( -36 ` <br /> c <br /> p <br /> h <br /> om 00 abm <br /> T N : m <br /> 8 : c : <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 'm p <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- y, <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 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- 8 8 <br /> plication. I a re t N <br /> p� g permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the o'e described praqses at any reas alble time or the purpose of inspection. m g <br /> m 3 n <br /> SIGN HER - // <br /> ( ' nature'ff owner or buin ontractor) - (date) <br /> x: <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> NNN ()i00 � m <br /> 88888888ai <br />