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on <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Co d -Mu a o <br /> APPLICATION FOR — LAND USE — PERMITS2. 3. <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the I c c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the Stale of W�scpnsin. H d <br /> I-0, s a <br /> OWZPlea'se Print) r Contractor or Surveyor or Agent o �" <br /> 9975 <br /> Adress / Address <br /> meati <br /> City, State, Zip Code City, State,Zip Code 2 <br /> Telephone Telephone <br /> Emergen /Fire No. and oad Name <br /> Legal Description (as indicated on tax statement) <br /> � O <br /> Permit(s) Applied for: 0 o <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage �t / /� <br /> Structure Use: �oo -f �I" /Jon tvo. /JoAl. o <br /> (f mily home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). X O <br /> 2. Show the location of the well (W), septic tank (ST), and drainf laid (DF). G 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. 11 o n <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 <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 CC <br /> dated by the owner. <br /> / m <br /> PLOT PLAN 1�0.1Cc7�e,d feO0 6:e � 'E 130W-e-, $" pe/Sawczl /'/o�JeP <br /> C teak �Y.5SP1,vv,I %R. I <br /> Py/rio��� <br /> v, <br /> m <br /> 0 <br /> 0 <br /> m <br /> o <br /> w <br /> Q � Pa,'(�� <br /> � I <br /> lulu 00 <br /> (n ( vmr DDp <br /> � E <br /> Sl/�Ifie. m nnm <br /> 9 < N N O J IJO <br /> P 4 T� <br /> _ O) m <br /> Wig : o <br /> �XJJ 8 ime c <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- : m <br /> edge and belief it is true,correct and complete.I adknowledge that I am responsible forthe detail and accuracy of all informs- •n m m! O <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- 8 a N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 a 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- N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have v, <br /> access to the above described premises at any reasonable time for the purpose of inspection. a g m <br /> m 3 A w <br /> N N A <br /> 8 s <br /> SIGN HERE '007 <br /> (signature of owner or bu�ilding^contractor) (date) Ft <br /> r tU)L7�I/V o <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED J m <br /> dm <br /> 888 $ 8y <br />