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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d '0CD 0 0 <br /> 2. APPLICATION FOR — LAND USE — PERMITS d 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c W <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the C" <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. H <br /> rs. o �_ r� S o 7C` <br /> OVW�I,NER (Please Print) / Contractor ofSurveyor or Agent o <br /> k5o�30 �eY�ata� Rd (dYi1rn IXGu.c . 3 <br /> Address Address <br /> Lt�etiS� 7(s �kcyy� <br /> er r L� S5/�9 ty ! '7kA�nrt�i 5�C�4�Q <br /> City, State,Zip Code City,Stale,Zip Code (b <br /> 7IV__ 96 - -73 � 7/s — SIRS � 7 <br /> Telephone Telephone 6 <br /> ��d GohGekp �� � 1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) 36 T'Y0 1211'?,_1 7 To�_�&F tt1/ uG <br /> ,ti 3 <br /> Permit9' <br /> Permit(s) d7`S 4d0 ! st Lam, ne.-50C. <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 00 <br /> Accessory Building — Sanitary Privy Subdivision P m <br /> Garage <br /> Structure Use: JQ Y dL c� .- v�(C�y r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> 1A <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). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). C 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 <br /> 300 ft. 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 N <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 <br /> dated by the owner. M <br /> m <br /> PLOT PLAN <br /> �f38 , SDS ro � <br /> o <br /> dub e y 0 0 <br /> J^ <br /> iG Z <br /> ug <br /> J,Sd <br /> f <br /> �rrJa iu� 5, i <br /> o c 0 a In <br /> m. Da'� aaN ` m Zt <br /> In <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- o m 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 informs- I w w O <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. <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 v, <br /> access to the above described premises at any reasonable time for the purpose of inspection. 3 8 <br /> m m p <br /> H [ N 8 <br /> SIGN HERE f' w <br /> ( ature M owner or building contractor) <br /> ZONING ADMINISTRATOR �1-r10�`ti r11 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED Yn�n 8 N o o b r'tn <br /> 88888888rmn <br />