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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator3 ? o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v y <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 <br /> 'v <br /> regulations of the State of Wisconsin. <br /> Jr n s <br /> OWNER (Please Print) Contractor or Surveyor or Agent o m <br /> i79b 32C S� ick . <br /> Address Address <br /> City,State,Zip Code City, State, Zip Code <br /> So 7- bV-- 9S3.3 <br /> TelephoneTelephone <br /> 2Sa 5 ,0 <br /> 4)Vr✓� a �✓ D r <br /> Emergency/Fire No. and Road ",-Te <br /> �o+s io - it - , - i-T, B Ioc k L mounds <br /> Legal Description (as Indicated on tax statement) <br /> o <br /> Permit(s) Applied for: 0 �- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit °� g <br /> Z o V <br /> Accessory Building Sanitary Privy o <br /> �— Sanita Pri Subdivision } <br /> Garage / f <br /> Structure Use: rh�+ ALI I -} S <br /> (family home/cabin, garage, addition, etc.) Mill <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). o m <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within R Q <br /> 300 ft. o n I <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 o <br /> to lake, river or stream, if applicable. J <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and CC <br /> dated by the owner. m <br /> PLOT PLAN t <br /> m <br /> ryb� o <br /> ' F <br /> as <br /> N �o o <br /> �a <br /> D <br /> ti J <br /> 1Z <br /> J �m oc �to � > a � m <br /> m. <br /> 0 3: ao_ N31 <br /> o m '< 01cmo.0 <br /> O J � 3 <br /> < V' : � N ,p <br /> 3 M/r/ O O 0 M <br /> m <br /> N Ei O <br /> m c C <br /> N ' p <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o : 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- �`--� w m a <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 $ $ <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 rn <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> 3 A <br /> SIGN HERE <br /> (si at re of owner o ilding contractor) <br /> (date) ` i o E x i <br /> i $ <br /> ZONING ADMINISTRATOR � <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o $ m <br /> $ 8 $ $ 8 $ $ Sm <br />