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C <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m a o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q m <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. �A '' / y <br /> ge-Lj Z ^�a On ri k a U i 1 f, Q r m D O <br /> f <br /> OWNER (Please Print) Comr tor or Surveyor or Agent 'a — ' <br /> 4 e" kj /�Q-�1� 3 m <br /> Address Adds /, <br /> !(tJ� <br /> 6- )LI IwJ r. L Qs, ArErr�� LcJ ; 's fTj <br /> City, State,Zip Code City,State,Zip Cod m <br /> �zE'C 7$c 7 <br /> Telephone T ephone <br /> Emergency/Fire No. and Road Name <br /> V 'l <br /> Legal Description (as indicated on tax statement) <br /> n Q <br /> Permit(s) Applied for: o °- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit 0 ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: I oU 8 <br /> (family home/cabin, garage, addition, 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 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 o <br /> 300 ft. a $ <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 <br /> to lake, river or stream, if applicable. M 0 <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 � <br /> PLOT PLAN <br /> m <br /> 0 <br /> m <br /> C:) I <br /> v � <br /> w <br /> ^ lO <br /> z <br /> I <br /> f <br /> m o c m m o a m <br /> o Dai <br /> wam s <br /> < : ZuC io0m $ <br /> o f T W i <br /> - m <br /> N[ G> ' ' O <br /> c . <br /> » : <br /> 8 : i C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs. m`n O <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- N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above describedemises at any reasonable time for the purpose of inspection. 8 0 <br /> T <br /> V N <br /> 9 m <br /> SIGN HER LCK!r=- <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR � 16Y'f/V N. g '- '. <br /> TOWNSHIP PERMITS MAY BE REQUIRED OfHn�u N n o o m <br /> °888888880 <br />