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/Y-) <br /> Burnett,County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w 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 c 1 l <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the �N <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. m m <br /> OWNEE (P(le se P i ) Contractor or Surveyor or Agent o <br /> o <br /> Address Address Z <br /> MOu ry o <br /> City, State,Zip Code City,State,Zip Code T <br /> Telepho Telephone <br /> '39o �`I <br /> Emergency/Fire No. and Road Name <br /> ) <br /> Legal Description (as indicated on tax statement) <br /> C <br /> Permit(s) Applied for: °. <br /> '^ r \ <br /> Dwelling Addition Filling/Grading Camping Unit S ° 'v <br /> Z v K) <br /> Accessory Building Sanitary Privy Subdivision ° Z' <br /> Garage <br /> 4- <br /> Structure <br /> Structure Use: 2�4 d r <br /> - -1 o <br /> (famil)home/cabin,Parage, addition, etc.) J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X C Vv <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfield (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 P c <br /> 300 ft. 3 o n <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m <br /> to lake, river or stream, if applicable. 0 <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. m $ <br /> PLOT PLAN 1 <br /> I � C,�r`� <br /> V) <br /> m <br /> 0 <br /> o G <br /> m <br /> rt <br /> /v ' I <br /> Z <br /> y <br /> �; C�Xpl12PG� �mi��ry ermt <br /> p � �� »gam <br /> A. aa`� aw amS <br /> a m < : w C w o 3 <br /> m <br /> G) � ': ID <br /> 8 m c C <br /> r ; m io 9 <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- : : _ , m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy o(all f a_ <br /> tion contained In this application(including any accompanying schedule)and I furtherdeclare that I raccignize that thied`'1{�i;-ear <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether td'issue a permit. I g m g <br /> further accept all liability which may be a result of the County of Bumett 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. m g <br /> w m n m <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR lFill l�� 1 �a^IhFl{�� 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED cNNn�?n J o 8 8 m <br /> $ 88 $ $ 8rma <br />