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011 L11 is <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator In -.4 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 H <br /> -cated 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 <br /> 'v <br /> regulations of the State of Wisconsin. m <br /> m m <br /> {/� t tjC�oc - S n m <br /> IXA� . 0 <br /> OWNER (Please Print Ft Contra 1Pr(s O eC r or Agent m <br /> ��Co �o,ev n C C <br /> Addres Addres LV%L � " Sy�--so 1 <br /> City, State, Zlip Code C y, Stat Hipp Code k moi` 03 <br /> Telephone Telephone ^' <br /> �- / -" - 5s� `/2-s W <br /> Emergency/Fre Noti. an godad Nar� <br /> tc <br /> Legal Description (as Indicated on tax state ent) <br /> n � <br /> Permit(s)Applied for: w <br /> a <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage ( p J J <br /> C 1 11r�. /4 <br /> Structure Use: 0 <br /> (family home/cabin, garage, addition, etc.) <br /> G <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 o <br /> 2. Show the location of the well (W),septic tank (ST),and drainflaid (DF). 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 Z <br /> 300 ft. o <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. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and Cy I n <br /> dated by the owner. (� Ne4 m <br /> PLOT PLAN t1— <br /> f --- — i o — <br /> I, o w <br /> r p <br /> -xJ Z <br /> M <br /> r) <br /> N <br /> o cm <br /> J Zm z 1 <br /> g O » . C <br /> so <br /> m m <br /> I declare that this application(including any accompanying schedule)has been examined by med to the best of my knowl- o I m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detai nd accuracy of all in w m N <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I i $ 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 03A m <br /> m Ap <br /> SIGN HERE 'r <br /> gn re owner or buil g contractor) �a ` 0i <br /> o , x [ <br /> ZONING ADMINISTRATOR <br /> w �wwuw <br /> TOWNSHIP PERMITS MAY BE REQUIRED ' 1 N N 'o o S m <br /> 8 <br /> N <br /> 888888 <br />