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L41 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 00 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d o <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 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 Wisconsin. N m <br /> o <br /> Pe to n_ F. w EpiJE. CalC/$/- S,4� -,c0 <br /> o <br /> s <br /> OWNER (Please Print) r Contractor or Surveyor or Agent o <br /> ,? � ya1L ce et G <br /> Address f G �jS 1 Pti �' I ,S yd y3 Address <br /> City, State, Zip Code City, State,Zip Code 1 <br /> 73�s _-Z) <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name 27 b YO 4 Cc <br /> Legal Description (as indicated on tax statement) <br /> o 0 <br /> o — <br /> Permit(s)Applied for: 0 <br /> 0 r <br /> Dwelling Addition Filling/Grading Camping Unit S o U <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 -- <br /> 1. Show the location and size of all existing buildings (ES) and all new buildings (NB) and Indicate North (N). M r <br /> 2. Show the location of the well (Vi), septic tank (ST),and drainfield (DF). 3 Z <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 <br /> 300 ft. .0 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 — H. 1 <br /> to lake, river or stream, if applicable. I <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H <br /> dated by the owner. m -Z <br /> PLOT PLAN ^/� �¢ 5A N d Z- <br /> �,k{ <br /> � I <br /> 0 <br /> ji <br /> N <br /> f O w <br /> 60 <br /> C 1 <br /> 910 Iv—nI <br /> — / o 7 <br /> D m (n � mr DD o <br /> m <br /> m °� Q� "am n :iD <br /> < i 42 goo 0 0 <br /> o E 0 M <br /> \ _ m <br /> C <br /> g : <br /> C <br /> I declare that this application(includ ng any accom a 'ng schedule)has been examined by me and to the best of my knowl- o_ I 1° `� m <br /> edge and belief it is true,correct t e.-M102 ledge that I am responsible for the detail and accuracy of all informa- rn m to O <br /> tion contained in this application(inc ding 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 Burnell 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- . d, <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have 7Q C) <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 8 <br /> - : 3 A 0 <br /> SIGN HERE <br /> Isi atu of owns uilding contractor) (date) x <br /> t <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAYBE REQUIRED rn <br /> U N N O m <br /> 8ggggrmJf <br />