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Burnett. County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator in o M -- a <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 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <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. H m° <br /> a = Qj <br /> f <br /> OWNX F�t P�leea��Use Pr,inContractor or Surveyor or AgeAgento <br /> t>�/xL25�irf: �LYOrf <br /> Addrgs 1224 �M / .Y�.E_) Adtlress <br /> City, State, Zip Code City, State, Zip Code <br /> Telephone Telephone <br /> Enter n�y FFire No. gndM,Na}ne�� C• _ / /3r;� <br /> Legal Description (ass Indicated on tax statement) �-f o n` <br /> G) U <br /> Permit(s)Applied for: o 0 <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z <br /> o <br /> Accessory Building Sanitary AL Privy Subdivision <br /> Garage 13061 , <br /> U <br /> Structure Use: 6W1m' I OQ <br /> (family home/cabiAlarage, additio c. 14 HC_. 'wl—) .1 -,— <br /> DIRECTIONS <br /> CDIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new bu11d1 reqs (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 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 ; <br /> 300 ft. on 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 n w <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 I <br /> dated by the owner. m a <br /> PLOT PLAN � <br /> I <br /> I <br /> G <br /> G� m <br /> V ~ <br /> o <br /> G —mom i <br /> W <br /> I� <br /> z <br /> v <br /> I <br /> f <br /> m o c m m o a g In <br /> m c <br /> . Dp`< a'aHzT. In <br /> v < Z m o m 3 <br /> z -o 1 <br /> o ma : <br /> 2 Tm <br /> �� o <br /> c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S : 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- <br /> mation <br /> 25m N [ <br /> mation i am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 a g <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 [ c)u, o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m g <br /> N : 3 A w <br /> N m A <br /> l0%3/9/ Hs : <br /> SIGN HERE <br /> (Signa re of owner or building contract: (date) �J o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MA BE REQUIRED N 8 0 0�$ m <br /> 89 888m <br />