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i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (n ; 0 0 <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 /> 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 applicable County Ordinances and the laws and <br /> regulatio of the State of Wisconsin. y <br /> E <br /> f <br /> OWNE (Please Print) Contractor or Surveyor or Agent o � <br /> AddressAddress <br /> z A sr✓t Amo ////�._•J-�O � l <br /> 7r 1 ^ <br /> City, State,�p Code City,State,Zip Code ` ) <br /> L%A/h�°,2i D G� <br /> T�eleohpp 6 9_ 6 Telephone <br /> Emergency/Fire No. and Road Name ,y f 97—/4/— <br /> 4/ p'A A <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> G) <br /> Dwelling Addition Filling/Grading Camping Unit v o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o � <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <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). C <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 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 -h v y <br /> 300 ft. on 'Z `o <br /> � 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 0 <br /> to lake, river or stream, if applicable. III o <br /> 5. If,separate plans are submitted 6y an architect,engineer,builder,contractor,etc.,the plans must be signed and C ( <br /> dated by the owner. <br /> PLOT PLAN SL) <br /> LE=As ! Q�tr'� 7-9 tokrYlOdS SEAMS Z <br /> i <br /> ff PnL/CA -/aAl .r- AIA A/ o <br /> IN <br /> �ek r�lr 1 44"r5 5Pf n) I'GfGmiT <br /> 1y1 �9 <br /> 0 fnv (nr DD <br /> a G H : `Z NO on 0 <br /> F T M <br /> Zi O <br /> .g m c <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 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m <br /> 9 P 9 P Y wm w O <br /> Informs- <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. 1 <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 emises at any reasonable time f r the purpose of inspection. am go <br /> a A us <br /> � m m <br /> SIGN HERE v <br /> (s'' nat of owner wilding cagractorl <br /> ZONING ADMINISTRATOR '— . g : E <br /> TOWNSHIP PERMITS MAY BE REQUIRED I m <br />