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-( <br /> L4 4-. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 CD t -0 -- o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <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 <br /> regu 'ons of the State of Wisconsin. n H d <br /> �G �)2 yyns e &--LJE.s ��2®eVr w a F <br /> OWNE�,RR (Ple�s a Print) Contractor or Surveyor or A ent 'o m' <br /> f-D, /S 9 x 5�� 7 - r1'I i L c ce 'b <br /> AddressAddr s I <br /> City, State,Zip Code ' City,State,Zip Code <br /> Telephone _ TS/ _ / Telephone �6 <br /> Emergency/Fire No. and Road Name /}� I'^ <br /> Legal Description (as indicated on tax statement) <br /> o <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: �Tr7 ¢ r- <br /> 0 <br /> (family home/cabin, garage, addition, etc.) Mill <br /> DIRECTIONS FOR PLOT PLAN DRAWING: a <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). () 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 ? c <br /> 300 ft. o n <br /> 4. Shaw 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. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H <br /> dated by the owner. m <br /> PLOT PLAN <br /> I C <br /> rau) i <br /> 0 <br /> 0 I <br /> o <br /> ( x <br /> D v (Or D DO <br /> m 0 c . 0 0 0 n <br /> M <br /> < m <br /> C <br /> o m <br /> 10 .20 : ..{ <br /> f <br /> on Tm a <br /> � ` m <br /> 8 [ n M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 0 m m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible forthe detail and accuracy of all informs- = : ` m N t7 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E 25 ro fn <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g m g <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 c,v, o <br /> access to the above d n d premises at any r onable time for the purpose of inspection. m 8 0 <br /> m 3 <br /> SIGN HERE <br /> (signatureof�ow,,n^er or bu mg contractor) (date) o x <br /> ZONING ADMINISTRATOR v n I' �' r��1 : . 8 . . <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> N UtNN OO <br /> 88H9888 ) <br />