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Qr' "'o-", <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; ' 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 0 3, <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 0 m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> v <br /> regulations of the State of Wisconsin. y °: <br /> � �ipY_ lir C�Ie�en �ra�eL �exCn,�ln,`�'Ivtn a � f <br /> 06NER (Pleas Print) Contractor or Surve or or Age <br /> 11� C�+ A(lY <br /> Arc r'SS Addr ss <br /> 4 . c1hky jVJ5 (1)T' 54009 �I.)� �eY 1l� 54883 <br /> City, State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) ° ro <br /> = 0 1 <br /> Permits)Applied for: w <br /> o = <br /> Dwelling Addition Filling/Grading Camping Unit � <br /> Z o <br /> Accessory Building Sanitary Privy � Subdivision ° } <br /> Garage O <br /> Structure Use: I V k (O <br /> amily home/cabin, arage, addition,etc.) Qi <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (N),septic tank (ST), and drainfield (DF). 3N <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within Z `c <br /> 300 ft. 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 o <br /> to lake, river or stream, if applicable. <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and a I <br /> dated by the owner. M :/ <br /> PLOT PLAN G <br /> 90G <br /> U1 <br /> Y e <br /> O <br /> O Ir' <br /> O M J <br /> O � <br /> w <br /> sQQ A,,1 CST <br /> w Z <br /> omm0agM <br /> n m <br /> n 0 a 0, ` T. K <br /> o .w m 1 <br /> k it TIN : 9 <br /> N : ON C : <br /> m <br /> m : M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> all informs- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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 $ $ [ <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- w <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have m N O : <br /> access to the above described premises at any reasonable time for the purpose of inspection. >p$w <br /> H O : <br /> SIGN HEREr`- h <br /> (sig ure owner or i Ing contractor) (dat ) r <br /> ZONING ADMINISTRATOR may! {1011 <br /> $ ' <br /> ON <br /> TOWNSHIP PERMITS MAY BE REQUIRED n . v p p, o O . m <br /> 88 $ 88 $ $ 8 vi <br />