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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -. 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 q 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 0. <br /> regulations of thheJ State of Wiscon in. H R <br /> �Op GDO� /19R Nn 2Tl„//+�,n 4 1-Vs ' a f <br /> OWNER (Please rint) Contractor or Surveyor or Agent o <br /> ,1/S 2r'L );=4 T.. m <br /> Address �(,lpA,( r Address V / <br /> ( J` <br /> City, State, Zip Code City, State, Zip C s c <br /> '1�S-�.S�j - 'L��/ -2-sl �z <br /> Telephone _ dL� Telephone <br /> Emergency/Fire No. and Road Name ,(��9 on versi e -!E• <br /> I � <br /> Legal Description (as indicated on tax statement) <br /> n L7 <br /> 0 <br /> Permit(s) Applied for: <br /> m r <br /> Dwelling Addition pl'*� Filling/Grading Camping Unit S g <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o m <br /> Garage <br /> Structure Use: Ads/ -8 m, ! �r �r 7 �L/�1��✓l � r <br /> (family home/cabin, garage, additio , etc.) - <br /> 0 <br /> 1A <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 <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 F W <br /> 30D 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 f,7 to lake, river or stream, if applicable. m G� <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. m <br /> PLOT PLAN G <br /> I <br /> I co <br /> m <br /> o` <br /> o <br /> O y <br /> Z <br /> 9 <br /> /0 Inc <br /> oc 2m moo m <br /> rep"ej. —tr3 goo 00 ,0 <br /> 9 £ <br /> M . M <br /> _. � [ a <br /> M <br /> 8 € ate : 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 yfn! ro u D <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 25 ro <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 o, v <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ <br /> SIGN HERE ` n <br /> (sig u of owner or ui ing contractor) (date) <br /> o : <br /> ZONING ADMINISTRATOR $ <br /> TOWNSHIP PER ITS MAY BE REQUIRED o o m <br /> 888x, <br />