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Fi72 <Qrl�l- <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � 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 . o. <br /> regulations of the State of Wisconsin. <br /> n f <br /> OWN <br /> ase rCo a t orSuror) 17Teny') o m <br /> ( (�"acO� I�j � � Cl <br /> Addres Addre <br /> r�ner L�lz DRQ) a X7�� (A01 <br /> City, Statb, Zip Codb City,StAte,Zip Code 0 <br /> Telephone Telephone I <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n_ 0 <br /> Permito lc. <br /> Permit(s)Applied far: H <br /> r <br /> Filling/Grading Camping Addition Fillin ° <br /> Dwelling 9 9 P g Unit <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> r <br /> Structure Use: o <br /> (family home/cabin, garage, addition, 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). � v u, <br /> 3. Show the location of any lake or flowage- If within 1000 ft. and the location of any river or stream-If within an Z <br /> 300 ft. ° 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 N- <br /> to lake, river or stream, if applicable. m ° <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 /> i IPLOT PLAN <br /> i <br /> J y <br /> no <br /> vo 13 <br /> �0, - ° <br /> o <br /> Z <br /> I <br /> o cm �,. : m <br /> . onaIa. . .2o <br /> Z ` : mZ° 3 <br /> f Ji ?I N: M <br /> M <br /> G)2 : O <br /> C <br /> 8i 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 informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- .. ` E 75 o N : <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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> r 3 <br /> m A a <br /> N i N O <br /> SIGN HERE (date) o x: <br /> (signature of owner or build' contra/nc]t�or)^ <br /> ZONING ADMINISTRATOR �� <br /> � .r°i,Nooi� m <br /> TOWNSHIP PERMITS MAY BE REQUIRED $ 8 $ $ $ $ $ $ N <br />