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I)^ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator -. 1 o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING AIMNISTRATOR:The undersigned hereby makes application for a Permit for the work described and w Nr! <br /> located as stfown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> o O <br /> regulations of the State of Wisconsin. 6 S <br /> 4titeCK f <br /> OWNER (Pleas PJ•�nt) ,( S, Contractor or Surveyor or Agent o m <br /> c�dress Address V <br /> City, St e, Zip Qo¢,eCity, State, Zip Code 3 <br /> //Kone (v.SS �( p Telephone d- <br /> ep <br /> g7� <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> 0 <br /> � o <br /> Permit(s)Applied for. ° ^" <br /> m � 7-1 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o ° <br /> T <br /> z 0 ro <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage 1 ` <br /> Structure Use: ku e1;lt P <br /> mily 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). O <br /> O ° <br /> 2. Show the location of the well (W) septic tank (ST),and drainfleld (DF). o w <br /> 3. Show the location of any lake or flowage-If within 1000 ft. and the location of any river or stream- if within on Z <br /> 300 ft. ° o <br /> 4. Show dimensions in feet ofthe following:(a) building to all lot lines,(b)building to center line of road,(c)building m y <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 Cy <br /> dated by the owner. m <br /> PLOT PLAN IZ <br /> Y rn <br /> � N <br /> 0 <br /> ° <br /> N <br /> P1 <br /> O <br /> � � f 1 <br /> 5e <br /> 9(,, t ► �� <br /> I09 <br /> 71D Z <br /> I <br /> oin - m > <br /> m. <br /> O £ J 4i <br /> -. � : <br /> = m <br /> l62 <br /> C <br /> g ` gym ' a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S 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- 1n 3 N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 7S m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ 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- w <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to havl�, ro g o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 F <br /> V A N . <br /> SIGN HER ` H ` n <br /> (signal a of own orb 'lding co ctor) date) I o , <br /> ZONING ADMINISTRATOR <br /> ww ww M <br /> TO NSHIP PERMITS MAY BE REQUIRED N o o m <br /> 888 88 <br />