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C)Iro � n <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn d '0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located 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 n (,A <br /> regulations of the State of Wisconsin. <br /> ILL D 04041) ;ELS a m 0 <br /> f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o � <br /> PIy m <br /> Address Address g W <br /> SUPERtab� �,Ja . 5Li`a��O <br /> City, State, Zip Code' City,State,Zip Code r <br /> Tele it Telephone <br /> 119(, SW+SS Te, <br /> Emergency/Fire No. and Road Name � <br /> Legal Description (as indicated on tax statement) o d <br /> Permit(s) Applied for: o °c <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o c <br /> v <br /> 2 B <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: I rhZ,� <br /> (famil home/cabin, jarage, addition, etc.) Iv�� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 I I <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 (S7), 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 P ) <br /> 300 ft. ana a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building �O N I� <br /> to lake, river or stream, if applicable. m L <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. m <br /> PLOT PLAN O <br /> K' <br /> N <br /> tw�tw O <br /> oN <br /> � � O <br /> O � � <br /> w <br /> � N <br /> I � <br /> oc710 <br /> � altin, Trrir <br /> m ' " m <br /> < E m o > 3 3 <br /> m 1 <br /> m <br /> G ^ m <br /> i G) C <br /> 5 <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my know l- . 5 : m m : ' a <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 informs- `: a m w O <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 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 /> m V A.. a . <br /> m m Fai <br /> SIGN HERE n <br /> (si nat a of own uilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE RE04�Itjt�b NOV I N h J ��� " <br /> N N u o o b m <br /> 8888 a, <br />