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n�( v4--" <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZQNING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <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 3 n <br /> regulations of the State of Wiscon <br /> VtLN4F-csWe2s' m <br /> o <br /> f <br /> OWNER (Please Contractor or Surveyor pr�Agent o o <br /> ,-7 �o / I.197S KJO.4- t �d S <br /> Add�)'"Y UY`"( Ad as r <br /> C%Stat , Zip Code City,State,ZipCom n <br /> Te ephone O / Telephone <br /> Emergen /Fire No. and Road ame <br /> ct . ,N fl +�IV --t=39 1�!- /(0L4-) <br /> Legal Description Indicated on tax statement) ° r <br /> n 0 <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading/Grading Camping Unit ° o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P m <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addit' n, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfleld (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 11 P c <br /> 300 ft. o Z n rq <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 C w. IvJ <br /> to lake, river or stream, if applicable. K <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and CC k <br /> dated by the owner. <br /> in <br /> e T <br /> PLOT PLAN J1, I I <br /> 4- <br /> m <br /> m <br /> { I� <br /> 0 <br /> o <br /> o_ <br /> l <br /> m oc� mio naF m <br /> o. a m a <br /> < � Z m o 0 2 3 <br /> Zi <br /> m z <br /> P M : Trn 1 : M <br /> m <br /> .8 : m `s c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m '� ' [ 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- 7S m u <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 agree to permit county officials charged with administering county ordinances or other authorized person to have u, g <br /> access to the above described premises at an reasonable time for the purpose of inspection. ' m 8 X <br /> m V A N <br /> N u O <br /> SIGN HERE <br /> (signat re r b i n tor) <br /> `NING ADMINISTRATOR r <br /> www wwwT <br /> TOW SHIP PERMITS MAY BE REQUIRED N p p $ <br /> $ 88 $$ 888fmn <br />