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Burneit County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Im o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. _ <br /> m Q <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 y L, <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 a \\ <br /> regulations of the State of Wisconsin. <br /> f <br /> DN (P Pri ) Contractor or SurveVor or Ag4at., o <br /> d ress' Addrgss -5 <br /> -i?,DLe�t Aid. �SS � <br /> City, State, Zip Code City, State,Zip Code 1 <br /> Telephone Telepone �� w <br /> Emergency/Fire No. and Road Name <br /> � P <br /> Legal Description (as indicated on tax statement) <br /> c� <br /> ' ,Perthit(s) APPTi�f'fo`r(°"' ..., U o <br /> m r- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o <br /> v <br /> 2 0 <br /> Accessory Building Sanitary 77 Privy Subdivision P } <br /> Garage �y { <br /> Structure Use: I <br /> 0 <br /> (family home/cabin, garage, a ition,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 /> 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 p c <br /> 300 ft. o n <br /> 4. Show dimensions infest ofthefoliowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building <br /> to lake, river or stream, if applicable. 4j o <br /> 5. If,separate plans are submt1^itt.cedtay an architect,engineer,builder,contractor,etc.,the plans must be signed and C J <br /> dated by the owner. VK 1 1111111 <br /> 41 <br /> PLOT PLA c)j /�` t)1J— r 1.lh1Cm �1/JSi TC �U /S l Ov I�Tt <br /> yq <br /> 444"' /LJ6 0ZeAL,— <br /> o <br /> fne`f`• C I�' <br /> �h oo <br /> � r <br /> fs z <br /> L." It <br /> t <br /> on U., mm �ag9 <br /> DJ J A a m <br /> m w o o. m S <br /> P .Z <br /> / J = U> <br /> c E <br /> € 8 € ate : C <br /> I declare that this application(includi m <br /> any accompanying schedule)has been examined by me and to the best of my knowl- 'S [ 1D 'D m <br /> edge and belief it is true,correct and c mplete.I acknowledge that I am responsible for the detail and accuracy of all infora- [ w m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ m i <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I gag <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 u <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g �. <br /> [ v ^ H i <br /> R Ap <br /> M in 8 <br /> SIGN HERE �: n <br /> (signature of owner or building ac r)� (dat x,, <br /> o : <br /> #NTNG ADMINISTRATOR 0 8 <br /> �qq � <br /> NN N p!O fJHNdI T <br /> TOWNSHIP PE ITS MAY BE REQUIRED <br /> 8 $ 88 $ $ 88m <br />