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r"� ) (61, ' ). <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS — <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 m <br /> located as shown 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 a Tj �J I <br /> regulations of the Sta//te, of Wisconsin. <br /> %2E2�k'/C hh ( - DAGG Y SF.CF a <br /> OWNER (Plea Print) �7 ComractororSurveyor orAgent <br /> 7'= <br /> � S"fONy _W <br /> 014 <br /> Address Address <br /> (.JE6 s K GtJ�sc 15 _7 0� o <br /> City, State,Zip Cade City,State,Zip Code <br /> 966 -C/190r �- <br /> Telephone � � Telephone <br /> Emergency,(Fir� No. and Qoad Nasm� '/ S <br /> Legal Di5scription (as indicated on tax statement) '(/o/ qb'a - 50/ <br /> n � <br /> 0 <br /> Permit(s)Applied for: 0 ;- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit ° o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P z <br /> Garage �c7ff� 0t <br /> Structure Use: ��/«' �IP�iZiai '5 ` - — o <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 2 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O <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 p <br /> 300 ft. o 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 mC,c� y (A <br /> to lake, river or stream, if applicable. Q) ; �( <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 <br /> i <br /> N <br /> 0� n_ <br /> o <br /> INo <br /> N <br /> Z <br /> m o c m <br /> N M <br /> n F m <br /> a m <br /> m <br /> m c i C <br /> g ' ma <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 lam responsible for the detail and accuracy of all informs- E H m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- [ 8 0'0 v, <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 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have O ,,, o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 8 N <br /> m a A uFi <br /> SIGN HERE <br /> (si at re of owner o ilding cony (date) s, <br /> o ; <br /> ZONING ADMINISTRATOR a g <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 88888888fmn <br />