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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) m o a <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 � y <br /> ° Ll <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 a V <br /> regulations of the State of Wisconsin. w m <br /> O/n s 1)1 �Ja>n tce, 92 , /Iv-K- n f <br /> O NER Please Print) Contractor or Surveyor or Agent o = <br /> A dre s Address <br /> egg/_e <br /> City, tate, Zip Code City, State, Zip Code <br /> -7- 173 -0?o37 <br /> Telephone Telephone <br /> F Bess �lie� <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) H 13 a^ `6 • 14 J 9 <br /> S IS y/ IS W Ak!_ e$ o2O.Uv o <br /> Permit(s) Applied for. P y S. �. 03 5'00 <br /> s a �icJ o 0 <br /> Dwelling � / dltion Filling/Grading Camping Unit <br /> z o <br /> Acce ildin Sanitary -F�riw7- _ Subdivision <br /> Garage �✓ i`I' <br /> Structure Use: P I� <br /> 0 <br /> (fa ily ho a/cabin, garage, ition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). C <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 3 co <br /> 300 ft. o 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 m y <br /> to lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and CM �I <br /> dated by the owner. M <br /> PLOT PLAN' IZ <br /> J Ike <br /> 1 <br /> v � <br /> w <br /> Z <br /> 7h y <br /> �l <br /> )) <br /> ,ndl 6- ma <br /> f^00b) /e ���dra0> <br /> m 0C ' N0i a ' m <br /> m. as a z = M <br /> OSte <br /> Z <. M <br /> e m <br /> C <br /> 8i <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- - g m 'm ? m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- m O <br /> 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 g m 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m ? 3 <br /> m V N <br /> SIGN HERE <br /> (signature f owner or bolOing contractor) (date) <br /> ZONING ADMINISTRATOR ` g <br /> H h <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 88188 $ <br />