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15Y? ce-� . <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m '11 i z <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and rn <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 o. <br /> regulations of the State of Wisconsin. <br /> w m_ <br /> f9Avl S. IO�jll(SD� a = <br /> OWN R {Please Print) Contractor or Surveyor or Agent o <br /> KOS/ -JDtFACSo c! <br /> Addre satii m <br /> 1 f�71 <br /> (f/Ld1_ Y�nan 0 nAddress <br /> Crty,DS' ti (i v/Z tate,Z1p Code 1_ City, State, Zip Code <br /> GU l `fB 30 <br /> Telephone // Telephone r <br /> Emergency/Fire No. and Road Name I <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s) Applied for: `» o � <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: <br /> r <br /> (family home/cabin, garage, addition, etc.) » <br /> DIRECTIONS FOR PLOT PLAN DRAWING: O <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 2 0 <br /> 2. Show the location of the well (W),septic tank(ST), and drainfield (DF). Q o <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within 11 o rn <br /> 300 ft. 11 a 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 <br /> to lake, river or stream, if applicable. M c <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. <br /> PLOT PLAN m v 1 <br /> r <br /> I <br /> M » <br /> 14 <br /> o <br /> C1 o <br /> _ <br /> LO i A3 f <br /> \ �� m o c m m n a m <br /> 9 0 < m C <br /> 0 m 0 = <br /> ym : r0 i <br /> O <br /> J € „ C, a <br /> e <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 m ' m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informa- p <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 g 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 officialscharged with administering county ordinances or other authorized person to have N <br /> access to the ab 'bed premi t a y re nable time for the purpose of inspection. m ' <br /> m 3 <br /> SIGN HERE a in 8 <br /> (si ur wne uilding contractor) (dWe) <br /> a/ ) <br /> ZONING ADMINISTRATOR f 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N o N " <br /> ut . 9 utoo . m <br /> 88888888mw <br />