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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0a o <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and �_ n <br /> regulations of the State of Wisconsin. H m <br /> N � <br /> -erSf(,re4 I <br /> OWNER (Please Print) Contractor or Surveyor or Agent o J <br /> Address Address <br /> ,� � Ilf'vp Cw� <br /> City, State,Ziode City,State,Zip Code <br /> Telephone Telephone <br /> Ee�-ilC A 2 rO <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> � L7 <br /> Permit(s)Applied for: o <br /> / 0 <br /> Dwelling ✓ Addition Filling/Grading Camping Unit S °^ <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: 0 <br /> (family home/cabin, arage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <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). 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 <br /> 300 ft. Z c <br /> 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 n y (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 I <br /> dated by the owner. n m I <br /> PLOT PLANtPJ <br /> Co <br /> c <br /> Sege <br /> r m <br /> o <br /> vi IIlL�7 <br /> Iv <br /> J 9 <br /> �yvdlo�-loh. o� YP./`mT g <br /> 1)eI�w fio ha„ '2 no Ir�SlcQe qua Fer ress� s�s�e'w i <br /> Ow crom <br /> ym n� o. m a — If <br /> N!� r'�Slol.k P,Ltn�(0�.�.c1 ^ m = Z c o m 3 <br /> /VT o Fes . Z+Q <br /> m <br /> obi 47 � O <br /> Oa c C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g I '� ' ; m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- .n m N! O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m N <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 g <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 v, <br /> access to the above described premises at any reasonable time for the purpose of Inspection. w g o <br /> T 3 n <br /> m 9 A H <br /> C H i 8 : <br /> SIGN HER <br /> (s' net re of owner o b ding contractor) (date) 1 <br /> ZONING ADMINISTRATOR g <br /> Y`(gNN ON.8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N N N O O <br /> 8888888 <br />