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n-(- (p <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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 a <br /> regulations of the State of Wisconsin. /' f, m Q <br /> 6RS1 Il)iSCBf)�x� {{ 0( s <br /> l <br /> OWNER (Please Print) ont ctor o urveyor o ant o .` � <br /> _ O <br /> Ad ss Add 5 1 <br /> irza �fil�'1IC� In f <br /> City, b�ate,Zip City, State, Zip Code <br /> - �Cod _ <br /> Teleg61 <br /> 0 I I V. 5S_ Telephone <br /> Emergency/Fire No. and Road Name (� <br /> r, <br /> Legal Description (as indicated on tax statement) o <br /> n L7 <br /> Permits) Applied for: o <br /> 0 <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit o °^ <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (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 o m <br /> 300 ft. Z `c <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. m pQ <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 <br /> dated by the owner. 40 m QM <br /> PLOT PLAN <br /> I I� <br /> es (rL <br /> V/4p <br /> ,3 0 <br /> o �m <br /> o <br /> w <br /> Z <br /> m o c m w o n g m <br /> n <br /> m. Da� aaN ami <br /> 9 < Q 900 0 m 3 <br /> 2 0 m .z M <br /> o f ,p " m m <br /> 8 i me : e <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S [ m m a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- yy!!m w E O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 25 m <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 access to the above described premises at any reasonable time for the purpose of inspection. [ m 8 m '. <br /> 3 n : <br /> m A m <br /> pA <br /> H i N 8 <br /> SIGN HERE u �^ <br /> (signature of owner or building contractor) (date) I '� <br /> ZONING ADMINISTRATOR �afl')PS 1 r IL+i- �`+1 . . g . . <br /> J (n <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 888 $ $ $ $ UM) <br />