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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 1 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m o �l}1 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of them <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a (� <br /> regulations of the State,off,Wisconsin. // y <br /> Clr I <br /> L. h/eIs6,� --7/,,,7 /ii o52l" 0 O <br /> f <br /> OWNER Please Print) Contractor or Surveyor or Agent o <br /> Addre Address <br /> City, State,Zip Code City,State,Zip Code >T <br /> Telephone Telephone <br /> r <br /> Emerycy/Fire No. and Roe ame <br /> Legal Description (as Indicated on tax statement) o <br /> n L7 <br /> Permit(s)Applied for: a e O <br /> w � <br /> Z <br /> Dwelling Addition Filling/Grading Camping Unit o °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision m <br /> Garage <br /> r � <br /> Structure Use: &C-j <br /> (family home/cabin, garage, addition, etc.) Milt <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). 0 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 <br /> 300 ft. on o g <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 OO <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. fA 1- <br /> PLOT PLAN Coiudt+&bti OF A"-tt— (, +-'I'I'Eoube -'�u Io2 U.k'C� V-Or 54or r ° $1J <br /> Goats r Boa,+u'_ nqa 6rJ 1 (3 <br /> wL+la+rf ar ld-ke-W 1 <br /> W N <br /> \14- LV <br /> n <br /> G o <br /> 0 <br /> o <br /> 4 <br /> w <br /> �FffcO /IY CTr \', ``''//� m o c m m o n E m <br /> l /K v m ` Amo ° M <br /> Z io ! : t° <br /> Lo. ,2 1 <br /> o £ Tto M <br /> G-y ---- —� = Cr m <br /> 8i <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S m 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- I <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- b" <br /> mation I am providing will be relied upon by the County of Burnett 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 <br /> m a m <br /> m m <br /> SIGN HERF <br /> (sign of owbudding contractor) (date) o i , <br /> ZONING ADMINISTRATOR =% `� ��hh 8 <br /> of <br /> 8 " <br /> TOWNSHIP PERMITS MAY BE REQUIRED dNN N o o m <br /> 88888ss8y <br />