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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0o + o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <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 3 n <br /> regulations of the State of Wisconsin. <br /> I\ <br /> 'I c n Ic,1�a,•d. 1 /ytt(.7"bt,n „ a o <br /> F <br /> OWNER (Pleas�rint) Contractor or Surveyor or Agent o <br /> '3X95 I)aa i /ia_ = D1 <br /> Address <br /> i� 95kE dil, T <br /> Ciry, State, Zip ode City,State, Zip Code <br /> �11�- y ;- o� y <br /> Telephone /. Telephone <br /> gen'C�"cy/Fire�No. and D03Road Name <br /> �1�- <br /> Legal Description (as indicated on tax statement) o <br /> G) <br /> Permit(s)Applied for: o <br /> 7 <br /> Dwelling Addition Filling/Grading Camping Unit 6 °^ <br /> Z o <br /> Accessory BuildingL Sanitary Privy Subdivision 0 <br /> Garage <br /> Structure Use: t <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <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). <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 N <br /> 300 ft. Z Q <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road, (c)building Q <br /> to lake, river or stream, if applicable. m 00 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C t <br /> dated by the owner. U1 <br /> f� m <br /> PLOT PLAN <br /> , N <br /> o <br /> /o / <br /> �— �a If J <br /> O 36 t <br /> a Z <br /> e <br /> J3 <br /> jvr <br /> t <br /> o c Z. W m D a : m <br /> a 00 <br /> < ` : � m 3 <br /> Z �' o ; m .zo `O 1 <br /> 0 4 " tn : 31 <br /> m <br /> . $ m 71 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know) o ! 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 informa- fn m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 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- <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 <br /> F <br /> n <br /> SIGN HERE <br /> (signat e f owner o building contractor) (date) <br /> ZONING ADMINISTRATOR �V11�- Al 1G 1 9 1992 8 <br /> TOWNSHIP PERMITS MAY BE REQUIREDN N 8 <br /> m <br /> . 888888880 <br /> 00 <br />