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(+7 ) (t-) ). <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o� o <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 u <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 n <br /> 0 <br /> regulations of the State of Wisconsin. y m <br /> �AIeRN S. /` pgje0e�-2 �� s M o <br /> OWNER ( lease Print) Contractor or Surveyor or Agent o <br /> Ad ess Address <br /> City, Itate, Zip Code City, State, Zip Code <br /> 1711•'- (;36-- -x3o/ <br /> 11 Telephone <br /> Telephone , n�0 en°. k �J p <br /> Emergency/Fire No. andRosa E f1 N i yy i �G <br /> Legal Description (as indicated on ta&statementf <br /> o <br /> M <br /> Permit(s) Applied for: 0 <br /> �/ m r <br /> Dwelling Addition L— Filling/Grading Camping Unit M S <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° ro <br /> Garage p 1 r I <br /> Structure Use: Bpzemet- I uAc6k- Poyne I k X 9 2 <br /> (family home/cabin,garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 o <br /> 2. Show the location of the well (W),septic tank (Sr), and drainfield (DF). 3 N <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within an Z C. <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 <br /> 45. <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 C J <br /> dated by the owner.,P160T PLAN <br /> an� ow Y <br /> N <br /> I b <br /> \I-.y-iel t(rJ O <br /> Jk <br /> a m <br /> Qr11 <br /> I <br /> 14 <br /> W ' 2 <br /> 7'� J.J o o. m <br /> D Q m O. N <br /> v q <br /> G H' : O J I° <br /> Z N p m Q <br /> ZC : <br /> 6 <br /> N W <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a <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. 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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have m N o <br /> access to the above scribed premises at any reasonable time for the purpose of Inspection. , 0 $% <br /> m m A <br /> 3 0-10 <br /> SIGN HE ` <br /> tytp of owner r wilding contractor) (data) ; o x <br /> ZONING ADMINISTRATO o ' <br /> TOWNSHIP PE MITS MAY BE REQUIRED <br /> $888888 $ <br />