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�, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d a <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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other ap licable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. <br /> -d V <br /> ewo Q, <br /> S C O <br /> OWNER (Plea rint) Contractor or Surveyor or Agent o m <br /> llSf7H La� m <br /> _ <br /> m <br /> Adc{ress Address I <br /> City, State,Zip Code' City,State,Zip Code <br /> jEr <br /> elephone Telephone <br /> Emergency/Fire No. and Road Name <br /> :z—lio 41Z <br /> Legal Description (as Indicated on tax statement) / <br /> Permit(s) Applied for: o0. <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> 1 } <br /> Structure Use: /4N!�Z / J�>y �' � 7147 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X 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 c <br /> 300 ft. o $ <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <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. <br /> PLOT PLAN <br /> m <br /> m <br /> Q�r � sir ie �r5c�r� <br /> -7GV <br /> tit <br /> � p ` J <br /> 0 o c m m n g m <br /> M <br /> < mo0 ,o= 3 <br /> Z o <br /> P m <br /> G) O <br /> g dci C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- I 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- l� G3: <br /> : 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. I 8 m 8 <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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m ' 3 g o <br /> f 3 AA <br /> N N O <br /> SIGN HERonen E [ <br /> gn ofr r b in rector) (date) <br /> ZONING ADMINISTRATOR 8 ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N O 8 m <br /> 1 N T N o m <br /> 88888 ' 8ai <br />