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rd <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (n 'a - 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m 7 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0 <br /> regulations of the State of Wisconsin. Q J H ° <br /> OWNER EPlease Print) Contract or Surveyor or Agent o <br /> Address Addr 't <br /> City, State, Zip Code City,State,Zip Code <br /> "hon <br /> 07 0 02 L <br /> Telephone Telephone <br /> 7 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: =` / 1= %_/V _'. i A/ /"`�. / % f . . <br /> Dwelling Addition '� Filling/Grading Camping Unit S <br /> �. <br /> Z o _ <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage ) <br /> r-�� (1 ice. ��_(� i�.,� �� A .�-. 1 �/ A! /�/.JfI CS kDOM r <br /> Structure Use: o / <br /> (family home/cabin, garage, addition, etc.) <br /> an <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 n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). G 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 11 v <br /> 300 ft. ON Z <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building n• <br /> to lake, river or stream, if applicable. mso <br /> 0 <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. (A <br /> m tJ,i <br /> PLOT PLAN <br /> �0.rLL�e <br /> o <br /> V <br /> 5�� ao PCl <br /> � M <br /> b � Z <br /> Z' <br /> T f <br /> 1001 k' T be, <br /> I mo` <br /> V- re � <br /> �� i Fake" �foPe ' <br /> m =VP <br /> Ka rn <br /> 1�t?'C I— m <br /> la4q <br /> w � C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all 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. I g 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 N <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 0 <br /> 3 <br /> 0 O A is <br /> W : N <br /> yr �9Z » s = <br /> SIGN HERE <br /> signature of owner or buildin c ntr to (date) E o <br /> ZONING ADMINISTRATOR 0 8 <br /> �. <br /> TOWNSHIP PERMITS MAY BE REQUIRED �n N N N o 8 `8 m <br /> 8888888ai <br />