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fV ( <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m -0o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <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 - ,C, <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and n t <br /> regulations of the State nof Wisconsin. <br /> OW R Please Print) f Contractor or Surveyor or Agent o <br /> O;V °' OCA <br /> AddressAddress ` <br /> � vL . �1� �t'ie �' <br /> City, St te,Z,j�AAC e� City, State,Zip Code <br /> St Re <br /> Telephohe Telephone <br /> Em gency/Fire No. and Roa Name �� <br /> _ sGL'� LGIT ,/G✓._� ��� R. <br /> Legal Description (as Indicated on tax statement) <br /> B 0 — <br /> Permit(s) Applied for: o �- _— <br /> Dwelling Addition Filling/Grading Camping Unit E <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: �!/'.( r <br /> (family home/cabin, garage, addition, etc.) <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). M O <br /> 2. Show the location of the well (W),septic tank (ST), and drainf laid (DF). C 3 <br /> on 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within <br /> 300 ft. Z <br /> a 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 � H <br /> to lake, river or stream, if applicable. M <br /> 5. <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 <br /> i y <br /> 18 o <br /> ll0 <br /> N � I� <br /> 0 <br /> " ' <br /> TPPN <br /> ti- <br /> O <br /> N_ <br /> n <br /> 7>< Z <br /> I y <br /> 5g 7G � 0 oc =. mmoa * m <br /> m. DK'� '- 'a m a A a <br /> 0 m' o m .z <br /> fes : T N M <br /> M <br /> N fin : <br /> m C <br /> g m m In <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S In <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m <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 g <br /> W : v A <br /> go <br /> SIGN HERE I <br /> (signat ow r or buildin actor) (date) <br /> ZONING ADMINISTRATOR y 8 <br /> fww �w W(w f(N T <br /> WNSHIP PERMITS MAY BE REQUIRED N N N N O O O m <br /> 88888888 vi <br />