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fA <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator En d 0 o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> oL\ <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <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 3 n V' <br /> regulations of the State of Wisconsin. y m a ) <br /> OWNER (Plese Print) I Contractor or Surveyor or Agent <br /> felly �larti� ` Tr4r m <br /> Address .� Address <br /> btil,'c h rpt ��' N. �(v <br /> City, State,Zip Code City,State,Zip Code <br /> I <br /> Telephone Telephone 2 <br /> r <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o (� <br /> Permit(s) Applied for: 0 �. <br /> Dwelling Addition Filling/Grading Camping Unit o o <br /> v <br /> Z p <br /> Accessory Building Sanitary Privy Subdivision ` m <br /> Garage <br /> Structure Use: �7c�t11 ��V�/ �I rCl�Y�, (1 r <br /> 0 <br /> (family home/cabin, garage addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: A <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (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 e <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 <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. m j <br /> PLOT PLAN <br /> rn) <br /> I � <br /> 0 <br /> o � � <br /> m <br /> w <br /> ro <br /> n� Z <br /> 7 <br /> 7 1 <br /> w O C m 0 a F m <br /> m <br /> a =nyy <br /> o y <br /> o < � ' � ii Zm z' <br /> Z.x N Q <br /> O m <br /> C <br /> C <br /> 8 : o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> Z f m <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- . <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a permit. 1 8 m 8 <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 agre to permit county officials charged with administering county ordinances or other authorized person to have <br /> 0 0 : <br /> access to the a ve described remi es at any reasonable time for the purpose of inspection. : m 8 <br /> 3 p N <br /> SIGN HERE d' <br /> ti I <br /> (signature of owner or building contr tor) (date) <br /> ZONING ADMINISTRATOR ! J4A �T ! 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N u, 0 0 0 9 m <br /> $ 8�� $ $ 8ai <br />