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6)1 r":) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS w 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 H ° (}� <br /> locaied'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. y <br /> OWNE Contractor or Surveyor or Agent o <br /> Addr7a Address <br /> 114 <br /> City, State, od City, State,Zip Code <br /> Telephone Telephone <br /> Emeree7�/F.�je NoJ�nd Road a e <br /> �L. /rw/JfJ TZe ?, 7ZlO& �//(� Lam, <br /> Legal Description (as Indicated on tax statement) <br /> n G Q <br /> Permit(s) Applied for: o 0 <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> 2 0 <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage _ <br /> Structure Use: j <br /> (family home/ca , garage, additi n, etc.) (� <br /> In <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). 0 <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 v c <br /> 300 ft. an o i <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. m <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 /> I <br /> PLOT PLAN U1 <br /> I <br /> C, m <br /> I G o <br /> o <br /> V <br /> o <br /> 0 <br /> 7� z <br /> I z <br /> 1) VJ (/� v (nr DDO V <br /> o c m m a F m <br /> Z0 o Z '� <br /> X! <br /> M <br /> mol O <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 1D ', i M <br /> 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- <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 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 u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g o <br /> m 3 <br /> SIGN HERE���//,/�I� .�// 5l".�Y) `f NO <br /> (s/q na ure of ownor building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O N rh <br /> u u O 8 `d m <br /> 88888 $ 8m <br />