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()Y' ( . <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS ;v 3_ 3 TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 20 <br /> y <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 <br /> regulations of the State of VAsconsin. H <br /> � 10 f <br /> W (Please P int) r ���-PContractor or Surveyor or AgeAt <br /> q <br /> �Ic.cra � — ll�S{Z°rS�� Address <br /> City, State, Zip C e City, State,Zip Code <br /> Telep(P�r��rone/ �12C,0� Telephone .� <br /> � '" UCS( f' <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) (G <br /> n 0 <br /> Permit(s)Applied for: 0 ' <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage r4-��� ae 1 <br /> Structure Use: ( u /� g,8 o <br /> (family home/cabin, 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). 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 in <br /> 300 ft. `f0' -fa &Vaf -1 Road" � o <br /> 4. Show dimensions in feet of the following:(a)build gto all lot lines,(b)building to center line of road,(c)building m m <br /> to lake, river or stream, if applicable. 0 <br /> 5. If,separate plans are submitted by an architect }y�yi'���tee�w,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. 4\? :�"Li 111111 <br /> ill <br /> PLOT PLANAlp- /r <br /> S <br /> Ni <br /> CIIMI <br /> \ <br /> 7 J 9 2..0 go -'U <br /> -X C'I (� f� _ a� 'a m A S <br /> a A2. i � w 0. 0r0 3 <br /> U p E [ m <br /> m <br /> g : <br /> n $ M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize 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. 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- N [ <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have u, o <br /> access to the above des d premises at any reasonable time for the purpose of inspection. : m 8 m . <br /> nm E v A w [ <br /> SIGN HE �� <br /> "�A�(signature of o ner or buildi g contractor) (date) <br /> ZONING ADMINISTRATOR arm ruT1°l <br /> rig <br /> TOWNSHIP PERMITS MAY BE REQUIREDN g 88 $ $ 88rmn <br />