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on Fo­�'?Ir-I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> N O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 17 z m <br /> w <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 0 <br /> regulation of the tate of Wisconsin H m <br /> U4 d !S7 4 /e S,� {TIW m <br /> OWNER (Please Print) 1/Comer ractororsurveyor 6rA <br /> A ress ,t� <br /> 1 N�JC 1� y C)I)C AddressC / C V/ <br /> City, State, Zip CodeO� ty,State,Zip Code <br /> Telephone E. Telephone lephone <br /> �bneta ( a <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) v <br /> Permit(s) Applied for: 6ay-6 q �. 0 � <br /> '�// w r <br /> Dwelling Addition Filling/Grading Camping Unit 1o ° <br /> z v <br /> V 1 <br /> cesso Buildin c � Sanitary O O Privy Subdivision g <br /> Garage ,� <br /> Structure Use: fc�lP . r <br /> (family home/cabi garage, addition, etc.) o <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 n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (DF). C 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 .1 P W <br /> 300 ft. IN z `v <br /> 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 n <br /> to lake, river or stream, if applicable. M o <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. w S <br /> to — <br /> PLOT PLAN <br /> N <br /> 0 <br /> ILS <br /> O T <br /> o <br /> O � <br /> w <br /> 0 <br /> Z <br /> D <br /> O c m ro o n m <br /> amy <br /> ° ° _mi a <br /> m <br /> U i <br /> G) o <br /> 8 <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.1 acknowledge that I am responsible for the detail and accuracy of all informa- h m w : O <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 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 per unty officials charged with administering county ordinances or other authorized person to have <br /> access to the above scri ed wises a ny reasonabl time for the purpose of inspection. m 8 <br /> m A w [ <br /> SIGN HERE 9=a <br /> Signa f own buil g ractor) (date) <br /> � <br /> ZONING ADMINISTRATOR i � 8 <br /> TOWNSHIP PERMIT MAY BE REQUIRED <br /> 88888 $ 8 am, <br />