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66;T <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. 0 — <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 c <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 <br /> regulations of the State of Wisconsin. <br /> T�iama5 Elrngost �G'/)c)/� 1��� a = o <br /> OWNER LPlease Print) Contractor or Surveyor or Agent o <br /> /O/ l9irz'/od23i� <br /> AoEkess Address y <br /> C245/T1719-1 f/) GcAv/i z�L� S7�) lei <br /> City, State,Zip C e ��j City,State,Zip Cod <br /> lay _ �j8 -3831 71j 3y� X33 <br /> Telephone Telephone I <br /> Emergency/Fire No. and Road Name � <br /> Legal Description (as indicated on tax statement) O ) <br /> ci <br /> Permit(s) Applied for: o ° <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o (� <br /> Accessory Building Sanitary X, Privy Subdivision P <br /> Garage �,-�n' 1 I .� <br /> Structure Use: ) I �ef/I n,ICU <br /> (family home/c bin, garage)addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M 0 <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (DF). 0 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 mill <br /> 300 ft. M Z <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building n a <br /> to lake, river or stream, if applicable. M o0 0 <br /> t <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C � <br /> dated by the owner. 1A <br /> PLOT PLAN <br /> N <br /> m <br /> A <br /> O <br /> IT o <br /> Z <br /> I <br /> 0 o c M. m m D c, F m <br /> 9 < Z 90. j <br /> Z m' <N-o' <br /> m <br /> m <br /> Ni moo : O <br /> 8c : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S "° i 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- O <br /> (including Yaccompanying ) recognize : N N <br /> tion contained in this application �ncludin an schedule and I further declare that I 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> a A m i <br /> A <br /> SIGN HER w: <br /> (signatuu I owner or building contractor) (date) <br /> uo , <br /> ZONING ADMINISTRATOR \9-lflr✓1 'P I LQ '6gr/r) __ g <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N o 8 99 m <br /> 88888999rmn <br />